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 senior security officer (CSO or equivalent) of the company 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 to be considered: Company is a for-profit organization Submitter is the senior security professional for the company Company has a US-based security program Company Name Company Main-page Web Address Headquarters Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of ColumbiaFlorida Georgia Hawaii Idaho IllinoisIndiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri MontanaNebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon PennsylvaniaRhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Where is this company incorporated? U.S. Business Sector Consumer DiscretionaryConsumer StaplesEnergyFinancialsHealth CareIndustrialsInformation TechnologyMaterialsTelecommunicationsUtilitiesUnknown Presidential Policy Directive 21 (PPD-21) Critical Infrastructure Sector ChemicalCommercial FacilitiesCommunicationsCritical ManufacturingDamsDefense Industrial BaseEmergency Services EnergyFinancial ServicesFood and Agriculture Government FacilitiesHealthcare and Public HealthInformation TechnologyNuclear Reactors, Materials, and WasteTransportation SystemsWater and Waste WaterUnknown Does this company 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: Less than $1 billion $1 billion-$5 billion $6 billion-$20 billion $21 billion-$50 billion $51 billion-$100 billion Greater than $100 billion 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. Senior Security Officer (CSO equivalent) Name Senior Security Officer Official Title Please check this box to confirm you are the senior security officer Are you a U.S. Citizen? YesNo If available, provide a brief professional profile or a link to your online professional profile. E-Mail Address Work Phone Cell Phone Mailing Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of ColumbiaFlorida Georgia Hawaii Idaho IllinoisIndiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri MontanaNebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon PennsylvaniaRhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Is this address the company's U.S. Security Headquarters location? YesNo Secondary Point of Contact Name Secondary Point of Contact Title Secondary Point of Contact Email Do you or other security staff have a U.S. government-granted security clearance? If so, list the type of clearance and issuing agency. Describe the company’s line of business and how the company directly supports, influences, or impacts U.S. national security. Describe the company's geographic footprint (U.S. presence by state/international presence by country). Describe the value proposition of the company to DSAC. Describe the company's U.S.-based security department, 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 department's reporting relationship to the company’s corporate legal department. Describe a top concern the security department is focused on this year, or a goal it is trying to achieve. Describe the security department’s level of engagement with the FBI local Field Office. FBI Field Office Albany, New YorkAlbuquerque, New MexicoAnchorage, AlaskaAtlanta, GeorgiaBaltimore, MarylandBirmingham, AlabamaBoston, MassachusettsBuffalo, New YorkCharlotte, North CarolinaChicago, IllinoisCincinnati, OhioCleveland, OhioColumbia, South CarolinaDallas, TexasDenver, ColoradoDetroit, MichiganEl Paso, TexasHonolulu, HawaiiHouston, TexasIndianapolis, IndianaJackson, MississippiJacksonville, FloridaKansas City, MissouriKnoxville, TennesseeLas Vegas, NevadaLittle Rock, ArkansasLos Angeles, CaliforniaLouisville, KentuckyMemphis, TennesseeMiami, FloridaMilwaukee, WisconsinMinneapolis, MinnesotaMobile, AlabamaNew Haven, ConnecticutNew Orleans, LouisianaNew York, New YorkNewark, New JerseyNorfolk, VirginiaOklahoma City, OklahomaOmaha, NebraskaPhiladelphia, PennsylvaniaPhoenix, ArizonaPittsburgh, PennsylvaniaPortland, OregonRichmond, VirginiaSacramento, CaliforniaSalt Lake City, UtahSan Antonio, TexasSan Diego, CaliforniaSan Francisco, CaliforniaSan Juan, Puerto RicoSeattle, WashingtonSpringfield, IllinoisSt. Louis, MissouriTampa, FloridaWashington, D.C. If applicable, FBI Resident Agency (FBI offices in smaller cities and towns within field offices) Describe engagements the company’s security department has had with other law enforcement and Intelligence Community partners. 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. 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. ReCAPTCHA