IIAG MEMBERSHIP APPLICATION FORM Annual Membership Fee: $15.00 (US Dollars) Payable to: Insurance Internal Audit Group (IIAG) Tax Id: 22-2478126 Mail to: Melissa H Hoover 305 N 3rd St. Halifax, PA 17032 PLEASE RETURN THIS NOTICE WITH YOUR DUES CHECK NAME: ____________________________________________ TITLE: ____________________________________________ COMPANY: _________________________________________ STREET: ___________________________________________ CITY / STATE / ZIP CODE: ____________________________________________ TELEPHONE: _(_______)_________________ FAX: _(_______)________________ Please include Area code with telephone number and fax numbers. EMAIL ADDRESS: _______________________________________________________ Note: Most communications by IIAG are now being conducted via the internet so an email address is required for prompt receipt of materials. If you have any questions, please feel free to visit our web site at : http://www.iiag.net *CHECK HERE (__) if you have complete charge of internal auditing in your organization or group. (    ) Number in department including yourself. (    ) Please indicate if you would be interested in being a discussion leader or session chair.