Association of Certified Fraud Examiners
Heartland Chapter
P.O. Box 460726 ● Papillion, NE ● 68046-0726
WEB: www.heartlandacfe.com
2016 INDIVIDUAL MEMBERSHIP APPLICATION
This application must be accompanied by a check payable to “Heartland Chapter ACFE.”
Mail your application and payment to the address above by March 1, 2016
Name
Employer
Position
Professional Designations
Mailing Address Preference: Home
Street
City
Telephone: Office
EMAIL
Office
State
Zip Code
Fax
(Check) If you DO NOT want Heartland ACFE to include your information on the online Heartland ACFE Membership
Directory located at www.heartlandacfe.com
New Membership Application
Membership Renewal
CHAPTER MEMBER ($20) – ACFE Number
Date CFE Obtained
You must be a CFE in good standing with the National ACFE organization.
CHAPTER ASSOCIATE ($25) – ACFE Number
You must be an Associate Member (Non-CFE) in good standing with the National ACFE
organization.
CHAPTER AFFILIATE ($25)
You are neither a CFE nor a member of the National ACFE organization.
CHAPTER AFFILIATE – STUDENT ($15) – Please provide a copy of your student ID.
You must be a full time or part time student.
PREVIOUS BOARD MEMBER ($0)
You are a previous board member that completed the full election term.
MEMBER INFORMATION UPDATE ONLY
Have you ever been convicted of a felony or misdemeanor involving moral turpitude, including
convictions expunged?
Yes
No
If yes, explain:
I certify that the above information is true and correct to the best of my knowledge.
Membership is subject to the approval of the Board of Directors at their sole discretion. By submitting
this application, the applicant hereby applies for membership in the Heartland Chapter of the Association
of Certified Fraud Examiners and, knowing that this association relies on the veracity of the applicant’s
statements herein as a condition and retention of membership, furnishes the above information.
Check the box to indicate that you agree with the above statements
Annual dues for the Heartland Chapter do not include annual dues for the National ACFE. Please call 800-245-3321
or visit www.acfe.com if you would like to join the ACFE or to obtain your ACFE Membership Number. If you
have any questions, please email us at: Secretary@HeartlandACFE.com This membership will be valid from
1/1/2016 until 12/31/2016.
Signature_____________________________________________________ Date___________________________