Membership Application – Pennsylvania Association of Licensed Investigators

All applicants for membership in the PALI must comply with the following: 1. Answer all questions on this application. 2. Submit Payment: A non–refundable application fee of $25.00 plus membership dues according to the following schedule, based on when the application is submitted: January 1 – June 30: $100.00 dues payment July 1 – October 31: $50.00 dues payment November 1 – December 31: $100 dues payment (will be applied to the following year) Type of Membership: * FullAssociateAffiliateService & Industry Full: Open to any individual who meets the eligibility requirements set forth by the Commonwealth of Pennsylvania and is licensed. Associate: Open to any individual residing outside of the Commonwealth of Pennsylvania and who is qualified to operate as a private investigator under the respective laws and regulations existing in that person's jurisdiction. Affiliate: Open to any individual engaged in the profession of private investigations, or private security services, or who exhibits and expresses an interest in furthering the standards and objectives of PALI. Service and Industry: Open to any individual or corporation that provides services or products relating to the private investigative industry and has an interest in furthering the standards and objectives of PALI.

PERSONAL INFORMATION: Name: * Date of Birth: Email Address: * Home Address: City: County: State: Zip:

PRESENT EMPLOYER Employer: Position: Business Address: City: County: State: Zip: Phone Number: Does your state, city, etc., require you to be licensed as an investigator? YesNo If so, are you licensed? YesNo By what agency / authority? Date license issued License # If licensed, describe how you acquired your investigative experience in support of licensure. Have you ever been denied an investigator's license or has your license ever been suspended or revoked? YesNo If yes, explain: Have you ever been terminated from a position of investigator? YesNo If yes, explain: Have you ever been arrested and/or convicted of a crime other than a traffic offense? YesNo (Note: an affirmative response does not necessarily preclude you from membership) If yes, explain:

BUSINESS AND PROFESSIONAL REFERENCE INFORMATION: Please list three (3) of your past employers or other professionnal references (such as attorneys or industry clients with whom you've worked) who are able to assess your qualifications for membership: Reference Name #1 Occupation/Position Phone Number Email Address Reference Name #2 Occupation/Position Phone Number Email Address Reference Name #3 Occupation/Position Phone Number Email Address

OTHER INFORMATION: If you would be interested in being a lecturer/speaker at a PALI event, please describe the investigation-related subjects(s) and your expertise: Optional: Please list the PALI member that is sponsoring your membership application: Do you pledge your support to the Bylaws and Code of Ethics for PALI (can be found at pali.org)? YesNo CERTIFICATION AND RELEASE OF INFORMATION AUTHORIZATION I am applying for membership in the Pennsylvania Association of Licensed Investigators, Inc. I understand that submitting false, misleading, or incomplete information on this application will result in revocation of my membership. I understand that all information provided to PALI must be done in writing. If it is necessary to augment or correct information, it must be in writing. I agree to abide by the Bylaws, Code of Conduct, and Code of Ethics of PALI. I will voluntarily surrender my PALI membership, if any violation of the Bylaws, Code of Conduct, or Code of Ethics is found, following proper procedures identified in the Code of Conduct. I have not tried to mislead nor conceal facts concerning my background or qualifications for membership. I further understand that if my application is accepted, any false, misleading, or incomplete statements on this application shall be considered sufficient cause for denial or termination of membership. I hereby authorize PALI to make any investigation of my personal, professional and employment history for the purpose of determining my eligibility for membership. This authorization releases and indemnifies any person, company or agency who furnishes such information from any liability whatsoever. A photocopy of this form shall be as valid as the original. This authorization is valid for 180 days from date of signature. I solemnly affirm, under the penalties of unsworn falsifications, that the contents of the foregoing are true to the best of my knowledge, information and belief. Applicant’s Signature: *

Application Date: *

SPECIALTY DATA SHEET FOR WEBSITE Please provide the following information for your page of the PALI website: Name Email Address Company Company Website Street Address City Telephone Cell Phone Fax County Of Licensing State Zip If licensed in multiple jurisdictions, include additional license information (county of licensing, state, zip) for each. Certifications: CPP CFE CFC CLI BCFE CII CPA Other Certifications: Major metropolitan area that you would like listed as closest to you:

Investigative Specialties Select the top three (3) specialties you would like your company to be listed under: Accident Investigation Accident Reconstruction Adoptions/Biological Parents Aerial Photography Arson Investigation Aviation Issues Background Investigation Banking Community Cell Tower Tracking Cellular Forensics Child Abuse Investigation Civil Investigation/Litigation Support Computer Forensics Corporate Investigation Covert CCTV Installation Criminal & Civil Investigation/Support Criminal Investigation/Support Crisis Management Custody & Support Issues Database Searches Debugging Services Domestic Investigation Drug Investigation Due Diligence Employment/Pre-Employment Issues Environmental Issues/Investigation Ethics Issues Expert Witness Explosives Financial Investigation General Investigation GPS Tracking Homicide/Death Investigation Insurance/Fraud Investigation Internal Theft Investigation International Investigation Interviews/Witness Locates Loss Prevention/Asset Protection Major Theft Medical Malpractice Missing Persons Nursing Home Abuse Personal Injury Investigation Photography Polygraph Services Process Services Product Counterfeiting Product Liability Investigation Profiling Protective Service Real Estate Investigation Risk Management School Security Security Consulting/Training Security Officer Deployment Security Surveys Sex Crimes Statement Analysis Surveillance Technical Countermeasures Trademark Protection Undercover Operations White Collar Crime Workers Compensation Investigation

After submitting the Application Form, click here to go to the Payment page