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NGISG Sharing Group Registration
If you are already a LEIU Member, do not complete this form.  Email ngisg@leiu.org to request access.

* Required 

CONTACT INFORMATION
First Name:  *

Last Name: *

Position/Title/Rank:  *

Agency/Organization Name:  *

Assignment / Role within agency: *


Does your LE Agency/Gaming Office Oversee: *
Regulation Only
Regulation and Enforcement
Enforcement Only

Zone: * (View Zone Map)

Business Phone Number:  *

Cell/24 Contact Number:

Email Address:  *  (must be an agency address)

Please re-type your email address: *


SUPERVISOR INFORMATION CONTACT
Full Name: *

Supervisor's Title: *

Phone Work: * 

Supervisor's Email Address: *
(Agency/Organization Email Addresses Only)


EXPERTISE (Optional)
Will display on Sharing Group Roster / Directory (if applicable)

WEBSITE ACCESS
Password: *
Create a password for site access / modify your contact information.  (min 8 characters; 1 numeric, 1 special)

All registration information is considered strictly confidential and will not be shared.