June 2007 Cism Exam Registration Form

Page 1
For Office Purposes Only
Please use black ink.
June 2007 CISM Exam Registration Form
Print in block letters or type.
Order No. ___________
US Federal ID No. 23-7067291
To register online, please visit the ISACA web site at www.isaca.org/examreg.
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Exam Date: Saturday, 9 June 2007
Date __________________________________
MONTH/DAY/YEAR
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I MR. I MS. I MRS. I MISS I OTHER _______________ 1. ISACA Membership#___________Indicate “PENDING” if you are applying for membership at this time.
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2. Name _____________________________________________________________________________________________________________________
FIRST
MIDDLE
LAST/FAMILY
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3. ________________________________________________________________________________________________________________________________________
IF JOINING AS AN ISACA MEMBER, PLEASE PRINT YOUR NAME AS YOU WANT IT TO APPEAR ON YOUR MEMBERSHIP CERTIFICATE.
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4. Certifications you currently hold: CPA_______ CIA_______ CA_______ CISSP_______Other (specify, excluding CISA) __________________________
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5. Residence address __________________________________________________________________________________________________________
STREET
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___________________________________________________________________________________________________________________________
CITY
STATE/PROVINCE/COUNTRY
POSTAL CODE/ZIP
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6. Residence phone _______________________________________________
Residence fax _____________________________________________
AREA/COUNTRY CODE AND NUMBER
AREA/COUNTRY CODE AND NUMBER
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7. Business name _____________________________________________________________________________________________________________
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8. Business address____________________________________________________________________________________________________________
STREET
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___________________________________________________________________________________________________________________________
CITY
STATE/PROVINCE/COUNTRY
POSTAL CODE/ZIP
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9. Business phone_________________________________________________
Business fax ______________________________________________
AREA/COUNTRY CODE AND NUMBER
AREA/COUNTRY CODE AND NUMBER
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10. E-mail________________________________________________________
11. Send mail to I Home I Business
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12. Date of birth _____/_____/_____
13. Field of
14. Educational
15. Work
16. Professional
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４
５
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MO DAY
YR
employment _____
level _____
exp _____
activity _____
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17. Size of organization _______
18. Size of IS/IT audit staff _______
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19. Size of information security staff _______
20. Level of purchasing authority _______
21. Exam language preference:
I
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English
I Japanese
I Spanish
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22. Exam center code _________ Exam center location name _____________________________________________________________________________
23. How did you hear
Indicate conference sponsor,
１
about the exam? _________
magazine name or explain other _____________________________________________________________________
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24. Authorization to release contact information to the local ISACA chapter (Y or N) __________
(This is not applicable to ISACA members, individuals joining at this time or exam passers granted provisional membership.)
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25. Do you wish to be notified of your pass/fail status and score via e-mail? (Y or N) __________ (Be sure you have included your e-mail address above.)
This is your only opportunity to receive your results via e-mail. Please be advised that your results letter sent by post is your official score result.
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26. Is CISM certification required for your current position or promotion? (Y or N) __________
I hereby apply to the Information Systems Audit and Control Association for exam by the association in the form of the Certified Information Security Manager
(CISM) exam and/or for membership in the association. By registering to take the CISM exam, I certify that I have read and agree to the conditions set forth in the
Bulletin of Information covering administration of the CISM exam; certification rules, policies and procedures; and the release of my test results; and I agree to
disqualification from the CISM exam and/or nullification of any exam score in the event that any statement or information provided by me to the association is false or
fails to include a material fact, or in the event that I violate any of the rules, policies or procedures governing the exam. By applying for membership in the
association, I certify that I will abide by the association’s Code of Professional Ethics.
I hereby agree to hold the association, its officers, directors, examiners, members, employees and agents harmless from any complaint, claim or damage arising
out of (1) any action or failure to act by me on behalf of the association, and (2) any action or omission in connection with my registration to take the CISM exam, any
exam given by the association, and any grade relating thereto and/or my application for membership. I understand that the final decision as to whether I pass the
CISM exam and/or am accepted as a member of the association rests solely with the association. I further understand that ISACA may inform the local ISACA
chapter and other appropriate parties of my having passed the exam. Notwithstanding the above, I understand and agree that any action arising out of or pertaining
to this application or the CISM exam must be brought in the Circuit Court of Cook County, Illinois, USA, and shall be governed by the laws of the State of Illinois,
USA. I HAVE READ AND UNDERSTAND THESE STATEMENTS AND INTEND TO BE LEGALLY BOUND BY THEM.
ここに英文で署名する
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27. Signature: ______________________________________________________________________________ Date:__________________________
(For your registration to be complete, you must sign on the line above.)
COMPLETE THE FEE REMITTANCE SCHEDULE AND METHOD OF PAYMENT ON REVERSE SIDE
9

W…
120
3
0
８０
２３０
more than
_______
$
S
US $
US $_______
US $
U
_________________
.
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$_________
$_________
F)
US $_________
Code: LASLUS44
CA member NO
but just look at the benefits—
Diners Club
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c 22-7157-8
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. THE EXAM AND DEFERRAL FEES ARE
see page 12
MONTH/YEAR
yment
Total Membership Fees (
SHIP FEES.
a
LaSalle National Bank, Chicago, Illinois USA
ABA No. 071000505 SWIFT
ISACA a/
ISACA • 1055 Paysphere Circle • Chicago, IL 60674 USA
ISACA • 3701 Algonquin Road • Suite 1010
Rolling Meadows, IL 60008 USA
+1.847.253.1443
Total Remitted (E + F)
(INDICATE CANDIDATE’S NAME IN TRANSFER INFORMATION)
American Express
_______________________________________________
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CA is not required,
I
１２３４−１２３４−１２３４−１２３４
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VISA Ｘ
カードの署名
I
________________________________________________________
________________________________________________________
uest is received in writing on or before 20 April 2007. All requests after that
www.isaca.org/examdefer
ship in ISA
______________________________________________________________
eceived on or before 2 May 2007 will be charged a $50 processing fee. From 3 May
I do not wish to be included on a mailing list other than for ISACA mailings.
Check payable to ISACA in US dollars, drawn on a US bank
Bank Transfer (see below) Date of transfer (mm/dd/yy)
MasterCard
YES! I wish to become an ISA
and realize the benefits immediately
Member
See page 7 for details.
Local chapter membership is required unless you live and work
50 miles/80km beyond the territory of a local chapter.
Chapter number ___________ (
Payment Calculation
Association dues
Chapter dues (see page 12)
New member processing fee
Method of P Please note: Your registration is not complete unless you have signed page 1 of the registration form.
CISM Exam Fee and Study Aid Total (E)
ISACA Membership Fee Total (if applicable) (F)
I I I All payments by credit card will be processed in US $
Account number
Print Name of Cardholder
Expiration Date
Signature
Cardholder billing address (if different than address provided on previous page):
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Bank transfer information:
Mail to:
Air Courier:
Fax to:
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２２
$_______
１５７
５１７
$_______
$_______
$_______
$_______
$_______
$_______
$_______
$_______
$_______
$_______
$_______
$_______
$_______
A
$_______
$_______
$_______
$_______
B
C
D
E
o request a deferral, please go to
100
80
60
80
80
60
60
member
S $
Non-ISACA
US $ 480
US $ 530
US $
U
US $
US $ 150
US $ 150
US $ 100
US $ 100
US $
US $
US $
US $
May 2007. If not, nonmember
360
410
7
5
6
0
40
75
75
60
60
40
40
—
n full before candidates are
ISACA
S $ 110
member
US $
US $
US $
US $
US $
US $ 110
U
US $
US $
US $
US $
US $
US $
Study Aid Subtotal
)
]
)
Illinois, USA residents add 8.75% sales tax OR
Texas, USA residents add 6.25% sales tax
Please add the shipping & handling charges
per chart based on total from line A
Exclude web downloads
Study Aid Total (A+B+C)
Exam Fee and Study Aid Total (1+D)
for product descriptions.)
.isaca.org/examreg
4.00 6.00 8.00 10.00 10% of Line A
No shipping charges apply
& Canada
www
Candidate’s Guide to the CISM Exam
) (available December 2006)
Within USA
$ $ $ $
) [
Candidates unable to take the exam are eligible for a refund of registration fees, less a US $100 processing fee, if such a req
(Please use black ink and print in block letters or type.)
(
CM-7
)
7.00
MDB-7W
) (100 questions—available March 2007)
) (300 questions—available March 2007)
) (100 questions—available January 2007)
12.00 17.00 22.00 15% of Line A
Continued—page 2
) (available April 2007)
) (300 questions—available January 2007)
& Canada
Refund:
Candidates unable to take the exam can request a deferral of their registration fees to the next exam date. Deferral requests r
) (available January 2007)
Outside USA
$ $ $ $
r
m
www.isaca.org/nonenglishbooks
o
(
MDB-7
www.isaca.org/shipping
olicy—
(See
CM-7J
CQA-7J
CM-7S
CQA7S
(
CQA-7JS
CQA-7SS
Deferral:
(See page 3 for product descriptions.)
ral P
) (100 questions—available November 2006)
)(300 questions—available November 2006)
please visit
: Sales tax and shipping charges do not apply to exam fees.
JAPANESE (
SPANISH (
JAPANESE (
SPANISH (
JAPANESE
SPANISH (
For standard delivery times and air courier options,
ee Remittance Schedule
June 2007 CISM Certification Exam Fee
Register Online (SAVE US $50,
Registration paid in full on or before 14 February 2007
Registration paid in full on or before 11 April 2007
(included in the fee is a copy of the
CISM Review Manual 2007
CISM Review Questions, Answers & Explanations Manual 2007
(
CQA-7
CISM Review Questions, Answers & Explanations Manual 2007 Supplement
(
CQA-7ES
CISM Practice Question Database v7
(400 Questions, Answers and Explanations Database—available December 2006)
CD-ROM version
Web download version (
CISM Review Manual 2007
I I CISM Review Questions, Answers & Explanations Manual 2007 I I CISM Review Questions, Answers & Explanations Manual 2007 Supplement I I
Shipping & Handling Rates for Study Aid Orders
Amount of Line A Up to US $30.00 US $30.01 - $50.00 US $50.01 - $80.00 US $80.01 - $150.00 Over US $150.00
Refund and Defer
date will be denied.
2007 through 1 June 2007, a processing fee of $100 will be charged. Deferral requests will not be accepted after 1 June 2007. T
NONREFUNDABLE. NO REFUNDS OR EXCHANGES WILL BE GIVEN FOR STUDY AIDS, ASSOCIATED TAXES, SHIPPING AND HANDLING CHARGES, OR MEMBER
CISM Registration F
NAME: ___________________________________________________________________________________________
F
1.
NOTE
STUDY AIDS:
ENGLISH
2.
3.
4.
5.
NON-ENGLISH
6.
7.
8.
ALL STUDY AIDS MUST BE PAID IN FULL PRIOR TO SHIPMENT
ALL STUDY AID SALES ARE FINAL. NO REFUNDS OR EXCHANGES
PAYMENTS SHOULD BE MADE DIRECTLY TO ISACA.
If registering at the exam member rate beginning on 1 January 2007, 2007 membership (new or renewed) must be paid in full by 31
fees will be added to the candidates exam registration and applicable exam study material. Any remaining balance must be paid i
permitted to sit for the exam and before results will be released.
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