LEAP MEMBERSHIP APPLICATION



INTERNATIONAL LEAP/CSCIP MEMBERSHIP APPLICATION

For new LEAP/CSCIP members located outside of the United States only

International LEAP/CSCIP membership is combined for individuals located outside of the United States. This combined application form must be submitted to the Smart Card Alliance for acceptance into the LEAP/CSCIP program and to enroll in the CSCIP certification training program. LEAP/CSCIP is open to all individual professionals working in the smart card industry in the United States and worldwide, regardless of whether their organization is a current member of the Smart Card Alliance. First year LEAP membership fees are INCLUDED in the International CSCIP smart card training and certification exam fee. Future LEAP membership is billed on a calendar year basis with proration during the second year.

International Certified Smart Card Industry Professional (CSCIP) designation requires the completion of the CSCIP smart card training course and CSCIP exam. A separate CSCIP Training, Documentation and Exam Order Form must be submitted for acceptance into the CSCIP certification program.

International LEAP/CSCIP application fee: US $50.00

|Name:       |Title:       |

|Company:       |

| SCA member company | Non-SCA member |

|Company postal address:       |

|City/Province/Country:       |

|Phone:       |Email:       |

|Number of years with company:       |Company website:       |

|Supervisor/Manager Name:      |Supervisor/Manager Title:       |

|Supervisor/Manager Phone:      |Supervisor/Manager E-Mail:      |

Please summarize your smart card industry experience (a minimum of two years experience in a

smart card-related field is desired). Please limit your response to 100 words or attach separate sheet.

|      |

Identify two personal smart card industry references:

|1. Name:       |Title:       |

|Company:       |

|Address:       |

|City/State/Zip:       |Phone:       |

|Email:       |

|2. Name:       |Title:       |

|Company:       |

|Address:       |

|City/State/Zip:       |Phone:       |

|Email:       |

Note: If you cannot meet all of the above requirements, you may submit a letter or email documenting why you feel you are qualified for the International LEAP/CSCIP program, for review by the Smart Card Alliance.

I have read the LEAP/CSCIP terms and conditions manual and understand the requirements for the program

International LEAP/CSCIP application fee: US $50.00

Payment by:

|Method of Payment: | MasterCard American Express Visa Wire Transfer |

| | |

| |International wire transfers: Bank of America 3745 Quakerbridge Road Mercerville, NJ USA 08619 Bank phone |

| |#: (1) 609-586-8200 |

| |International SWIFT # BOFAUS3N, SCA Bank Account # 381 018 973 631 |

|Name on Card |      |

|Card Number |      |

|Billing Address: |      |

|(Including street, city, state| |

|or province) | |

| |      |

| |      |

|Postal Code: |      |Country:       |

|Expiration Date |      |Card Security Code:       |

|Authorized Signature: | |Date:       |

Fax completed form to: 1-609-587-4248

For questions, call 1-800-556-6828 or email us at LEAPinfo@

Smart Card Alliance

191 Clarksville Road

Princeton Junction, New Jersey 08550 USA

(1) 609-587-4208

leapinfo@

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