ICERM Academic Sponsorship Commitment Form
After successful completion of the form, you will receive a response within 1 to 2 business days with additional information about your sponsorship and an invoice.

Juliet Duyster can answer any questions you may have. She can be reached at (401) 863-5018 or juliet_duyster@icerm.brown.edu.

Check appropriate level: *
Required
Start Date: *
The standard sponsorship dates are September 1st through August 31st. If you are joining for the current year after September then we will prorate your membership cost.
MM
/
DD
/
YYYY
Name of Institution/Academic Department: *
Your answer
Contact Name: *
This person will be contacted before any funds are spent and will be added to the ICERM listserv.
Your answer
Contact Mailing Address: *
Your answer
Contact Phone Number: *
Your answer
Contact Email Address: *
Your answer
Departmental Website: *
To be used as a link on the ICERM Academic Sponsor website.
Your answer
Name of your department as it should appear in ICERM marketing materials and online: *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of ICERM. Report Abuse - Terms of Service - Additional Terms