FBI CITIZENS’ ACADEMY ALUMNI ASSOCIATION
MEMBERSHIP FORM
Name: ______________________________________Class City/Year___________________________
Home Address_______________________________________________________________________
Email Address________________________________________________________________________
Home Phone _________________________________Cell Phone_______________________________
Company Name_______________________________________________________________________
Position_____________________________________ Phone Number___________________________
Company Address _____________________________________________________________________
Company Email_______________________________________________________________________
Which phone number is best to use to contact you?___________Which Email?_____________________
What unique skills and or professional expertise do you possess? For example: speak a foreign language. ___________________________________________________________________________________
Upon answering yes to any of the questions below, please provide a signature under each question.
May we add your information to the chapter membership roster? Yes No
signature:__________________________________________________________________________
Can we add the information from this application to the National Membership Database? Yes No
When you join the local FBI Citizen Academy Chapter, you will also become a member of the FBI National Citizens’ Academy (FBINCAAA) which enables your membership information to be shared with the FBINCAAA.
signature:_____________________________________________________________________________
Would you like information on InfraGard, and thus allow the FBICAAA Membership Coordinator to forward your information to an InfraGard membership person? Yes No
signature:_____________________________________________________________________________
The FBINCAAA is a private, nonprofit organization and not part of the FBI.
Please submit this form along with your payment to:
FBI Omaha Citizens’ Academy
Alumni Association
P.O. Box 8005
Omaha, NE 68108
NAME:___________________________________________
What interests you the most?Please circle
Board Membership
Golf tournament (volunteer? participant?)
Fundraising
Event Planning
Coordinated projects with similar organizations (US Attorney, InfraGard, etc)
Child Safety ID Kits
Safe Online Surfing presenter
Presenting programs on Elder abuse/fraud
Alumni Shoot (volunteer? participant?)
Budget/Finance
Family Events
Social Events with FBI personnel
Holiday Activity
Membership recruitment
Web development
Newsletter
Travel to Washington for tour of FBI Headquarters and Quantico
Travel to regional and national meetings
Annual Dinner
Anything else you can suggest?
Membership term requested:
Annual ($50.00) ______
*Lifetime ($250.00) ______
*Membership dues are $50 per calendar year with a lifetime membership option for $250. The lifetime option can be taken at anytime but credit is not given for prior years’ dues.
Please contact the following Omaha FBINCAAA Executive Board members to volunteer for activities or committees:
Scott Berryman: (402) 884-2595, scottberryman@cox.net
Surasee Rodari: (515) 245-2435, srodari@gmailcom or srodari@bankerstrust.com
You may also contact Sandy Breault, Media and Public Affairs Coordinator, FBI Omaha Office
(402) 530-1582, Sandra.Breault@ic.fbi.gov
The FBINCAAA is a private, nonprofit organization and not part of the FBI.
Please submit this form along with your payment to:
FBI Omaha Citizens’ Academy
Alumni Association
P.O. Box 8005
Omaha, NE 68108
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