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Intelligence Liaison Officer Program Registration
Please complete the form below, no partial applications accepted.


CONTACT INFORMATION
First Name  *

Last Name *

Position / Title / Rank:  *

Work Phone: (###-###-####) *

Mobile Phone: (###-###-####)

Email: * (Organization Email Addresses Only)

WEBSITE ACCESS
Password: *
Create a password for site


INFRAGARD MEMBERSHIP
Currently an Infragard Member?
Yes
No
Infragard Chapter Name:

Infragard Membership #:

Scan and attach your Infragard membership card
:


SECURITY CLEARANCE

Do you have a Security Clearance?:
Yes  No
Cleared Through:
FBI DOD DHS N/A
If cleared through other state below:


 

COMPANY / ORGANIZATION NAME *

Address: *

Address 2: 

City: *

County: *

State*
  Zip Code:*

SUPERVISOR / EMPLOYMENT VERIFICATION CONTACT
Supervisor Full Name*

Supervisor Title*

Work Phone:* (###-###-####)

Supervisor's Email Address:*
(Organization Email Addresses Only)

Confirm Your Supervisor's Email Address:*

BACKGROUND INFORMATION

Have you ever been convicted of felony?
*
Yes No

Have you been convicted of misdemeanor in the last 7 years? *  Yes No
(if yes describe below)


Are you a U.S. Citizen or
Legal Permanent Resident?
*
Yes No

 

DESCRIPTION OF FACILITY OR NATURE OF BUSINESS
* Description is required to substantiate the need for inclusion in the ILO Portal

SECTOR INVOLVEMENT (Check all that apply)
*Required  Select "Other" if not applicable
Agriculture and Food
Banking and Finance
Commercial Facilities
Chemical
Communications
Critical Manufacturing
Dams
Defense Industrial Base
Emergency Services
Energy
Healthcare And Public Health
Government Facilities
Information Technology
National Monuments and Icons
Nuclear Reactors Materials and Waste
Postal and Shipping
Transportation Systems
Water

Other Sector (please specify)

All registration information is considered strictly confidential.