MACVSA ASSOCIATION

MEMBERSHIP APPLICATION

Please complete this application and forward it to the address at the bottom of this application. Your application for membership will be promptly processed. A specific requirement to join the MACVSA Association is graduation from a Certified Examiners Course (CEC).

Name:                 _________________________________________________________

Dept/Organization:    _________________________________________________________

Bus. Address:         _________________________________________________________

City:                 ____________________________  St: ______  Zip: __________

Phone:                ____________________________

E-mail Address:       ____________________________  Fax: ______________________

CVSA Basic Certification:

     - Instructor:    ____________________________  Grad Date: _______________

     - Specialties:   ________________________________________________________

CVSA Recertification: (most recent)

     - Location:      ____________________________  Grad Date: _______________

Polygraph Qualified?  Yes ___      No ___

     - School:        ____________________________  Grad Date: _______________

     - Specialties:   ________________________________________________________

Topics or speakers that you would like to see at a continuing education training seminar:

I certify that all information contained in this application is complete and true to the best of my knowledge. I understand that any material omission, misrepresentation or falsification of this information is grounds for dismissal or refusal of membership to the CVSA Association. I hereby authorize investigation of all statements contained herein and give permission to contact any or all of my previous employers, references, and/or schools attended for information.

_____________________________________________________   ____________________
Applicant's Signature                                   Date

Mail this application and a copy of your NITV CEC or recertification certificate, annual menbership dues ($60.00), and the one-time membership application fee ($15.00) to:


     S. Thomas Vaughn, President
     #6 N. Washington St.
     Millersburg,  Ohio  44654
     E-mail:  thomas.vaughn@millersburgohio.com
     (330) 674-5931