DSAC Membership Application Form

Membership and Engagement Committee voting sessions are held quarterly. Please allow four-to-six months to receive an application decision.

The Domestic Security Alliance Council (DSAC) is a corporate membership program. This application must be submitted by the U.S.-based senior security executive (CSO/CISO or equivalent) of the organization applying for membership. Please make every effort to provide accurate and up-to-date information. All information is required and will be verified. You may direct questions about this application form to DSAC@fbi.gov.

PLEASE NOTE: Applications must meet the following criteria:

Company generates $2 billion or more in annual U.S. revenue
Company is a for-profit organization*
Company has a U.S.-based security component
Company has a direct impact on national security or economic stability, and contributions to FBI and DHS mission critical objectives
Company has established and maintains a working relationship with its local FBI field office

*Exception for Healthcare and Public Health Sector

Organization

Organization Name

Organization Main-page Web Address

Headquarters Address

City

State

Zip Code

Where is this company incorporated?

U.S. Business Sector

Presidential Policy Directive 21 (PPD-21) Critical Infrastructure Sector (you may select more than one)

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Does this organization belong to a parent company? If so, please provide the name of the parent company, address of the parent company headquarters, as well as contact information for the parent company's senior security officer.

Most Recent Annual Revenue

Most Recent Fortune 1000 Rank

Please check this box if the company is listed in the Fortune 1000

Number of Employees Worldwide

Number of Employees in the U.S

U.S.-based Senior Security Executive (Self)

Please check this box to confirm you are the U.S.-based senior security executive

Name

Title

Security Function Portfolio (you may select more than one)

Are you a U.S. Citizen?

If available, provide a brief professional profile or a link to your online professional profile.

E-Mail Address

Work Phone

Cell Phone

Work Mailing Address

City

State

Zip Code

Is this address the organization's U.S. headquarters location?

yes no

Name

Title

Security Function Portfolio (you may select more than one)

Work City

Work State

Organization Details

Describe the organization's line of business.

How does the organization directly impact national security or economic stability?

Describe the company's geographic footprint (U.S. presence by state/international presence by country).

Describe the organization's U.S.-based security component, including its functions, key areas of responsibility, and number of staff. Please include information on both physical security and information/cyber security.

Describe the security component's reporting relationship to the organization’s corporate legal department.

Describe the security component’s level of engagement with the FBI local Field Office.

FBI Field Office

List any certifications or areas of expertise you or other security staff have.

List any professional associations to which the company or individual security staff belong or support. Examples include but are not limited to AGA, AFCEA, ASIS International, CLIA, ISAC related groups, FSR, InfraGard, ISMA, NICB, OSAC, Sector Coordinating Councils, etc.

Subsidiary companies of a DSAC member company may receive limited access to DSAC through its parent. The member company assumes responsibility for its subsidiaries participating in DSAC. As the member company sells and acquires permitted subsidiaries, it is the member company’s responsibility to notify the DSAC Program Office of updates. If your company owns other companies, you may list which subsidiaries, if any, you allow limited access to DSAC:

By submitting this form, you acknowledge that your company will be asked to sign a Membership Operating Agreement before your company can participate in DSAC activities if accepted into the DSAC program.

Privacy Act Statement

Authority: The FBI’s collection of an applicant and member information is authorized under: Title 28, Section 534 28 CFR. 0.85. Providing this information is voluntary, but failure to do so may result in your application being denied.

Principal Purpose and Routine Uses: The information collected will be used for the principal purpose of verifying your identity and confirming that you are qualified to be an authorized user of the DSAC Portal. As part of this assessment, the collected information may be used to assist in determining approval, denial, revocation, or renewal of access to the DSAC Portal and the authorization to receive DSAC-sensitive information. This information may also be used to periodically verify that you continue to meet account eligibility criteria for the DSAC Portal. In addition, your information may be disclosed as permitted by the Privacy Act of 1974, 5 U.S.C. 552a(b), pursuant to all applicable routine uses established in the following FBI System of Records Notices: FBI-002, The FBI Central Records System, 63 Fed. Reg. 8659, 671 (Feb. 20, 1998), as amended; and the FBI’s Blanket Routine Uses, 66 Fed. Reg. 33558 (June 22, 2001), as amended.

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DSAC Membership Application Form

PLEASE NOTE: Applications must meet the following criteria:

Organization

U.S.-based Senior Security Executive (Self)

U.S.-based Delegated Security Executive (Secondary POC)

Organization Details