Special Interest Group
for IIAS Standards
Online Membership Application
Instructions:
  • Enter ONLY ONE Membership Application per Tax ID number.
  • Do not enter multiple membership applications for multiple store locations under the same Tax ID number.
  • Per IRS regulations, there are several types of Health Care merchants that are not required to have an IIAS system or 90% rule exemption. This includes doctor’s offices, hospitals, dentists, medical labs, vision centers and others because the services they offer are strictly health care related. These businesses only need to ensure they have the proper Merchant Category Code (MCC) assigned to their business and transmitted in the card authorization request. SIGIS membership will not assist these merchants, if you are in one of these merchant categories, do not enroll for SIGIS membership.
1) Indicate Your Direct Material Interest in Corporation by Selecting Primary Type of Business:
IMPORTANT: Do not apply if you are the following: Doctor’s offices, hospitals, dentists, medical labs, vision centers and others because the services they offer are strictly health care related.

 Acquirer/Processor: Bank/processor that enables retailers to accept card payments
Issuer/Processor: Bank/processor that issues payment cards to consumers
Manufacturer: A company that manufactures healthcare products
Merchant/Retailer: A store/business that accepts card payments, i.e. a pharmacy
Payment Card Network: A company that process credit card transactions
Plan Adminstrator: A benefits providers who administers company insurance programs
Third Party Service Provider (TPS): A company that provides a point of sale software solutions to accept card payments
2) Primary Organization
Organization Legal Name: max 41 chars
Company Website Url: optional
3) Primary Contact  Lead Contact for non-legal notifications and may also be the contact participating in SIGIS activities depending on level of membership:
First Name:
Last Name:
Title:
Work Address(Line 1):
Work Address(Line 2): optional
City:
State:
Zip:
Phone: (nnn-nnn-nnnn)
Secondary Phone: (nnn-nnn-nnnn) optional
Fax: (nnn-nnn-nnnn) optional
Email(Unique for each contact):
Please note if you are applying for multiple memberships (for each Tax ID), email addresses should be unique for each company contact.
4) Notice Contact Person for purposes of receiving official notices pursuant to the Governance Documents *:
First Name:
Last Name:
Title:
Address(Line 1):
Address(Line 2): optional
City:
State:
Zip:
Phone: (nnn-nnn-nnnn)
Secondary Phone: (nnn-nnn-nnnn) optional
Fax: (nnn-nnn-nnnn) optional
Email(Unique for each contact):
* The Corporation is under no obligation to send communications other than those that are required by the Governance Documents.
5) Billing Contact:
First Name:
Last Name:
Title:
Address(Line 1):
Address(Line 2): optional
City:
State:
Zip:
Phone: (nnn-nnn-nnnn)
Secondary Phone: (nnn-nnn-nnnn) optional
Fax: (nnn-nnn-nnnn) optional
Email(Unique for each contact):
6) Alternate Contact  participating in the Corporations activities:
7) Select one category of membership. By electing a category of membership and executing the Membership Agreement, Applicant is confirming its willingness to pay the financial obligations for such category of membership:
Please note that Tier 4 financial obligations must be paid by credit card.
Initial Participation Fee: $5,000 one-time payment. Annual Membership Fee: $3,750 due upon membership approval and annually thereafter in the month of membership anniversary. Eligible to be nominated and elected to the SIGIS Board of Directors or Management Committee, plus all Tier 3 privileges.
Annual Membership Fee: $750 due upon membership approval and annually thereafter in the month of membership anniversary. Eligible to participate in SIGIS Working Groups, plus all Tier 4 privileges.
Annual Membership Fee: $100 due upon membership approval and annually thereafter in the month of membership anniversary. Basic SIGIS privileges to enable acceptance of FSA/HRA cards through SIGIS Certification process or self registration under the “90% Rule”.
8) Legal Agreement:

This Agreement must be accepted by a representative of the Applicant that is authorized to commit the Applicant to all of the terms of this Agreement. By accepting this Agreement, the person represents and warrants that he or she has been so authorized, has read and understood this Agreement and all other Governance Documents, and has sought or waived the right to seek legal counsel prior to executing this Agreement.

The Member gives permission for its name to be listed in the SIGIS Members List on the SIGIS website.
Primary Organization
Primary Organization Address
Name of person accepting the agreement above
Title of person signing
Email of person signing
Telephone of person signing
(nnn-nnn-nnnn)
9) Fees:
Your SIGIS membership application will be reviewed by SIGIS within 5 business days. If your application is approved a payment link will be sent via email to the email address listed on the application.

Initiation Fee: US $0.00
Annual Fee: US $100.00
Total Amount: US $100.00
Selecting, I Accept – Submit Application will submit your application to SIGIS for review. Upon approval a payment link will be sent to pay for the membership dues by credit card.
** Note: Tier 4 members are required to pay by credit card.