Institutional Group Membership Interest Form

Fields marked with * are required.

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Thank you for your interest in an Institutional Group Membership. Please complete as much information as possible. Email info@idec.org with any questions.

Institution Name *
Contact Name (This individual will serve as the Institutional Contact): *
Contact Phone Number: *
Contact Email Address: *
Please share the Program Name at your Institution *
Please list the Degrees Offered at your Institution *
(Maximum characters: 2000)
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How many Professional Members will be part of your Institutional Group Membership? (Minimum of Four) *
Please share the names of your Professional members.
(Maximum characters: 2000)
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Please share the emails for your Professional members.
(Maximum characters: 2000)
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How many Graduate Members will be part of your Insitutional Group Membership?
Please share the names of your Graduate Members.
(Maximum characters: 2000)
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Please share the email addresses for your Graduate Members.
(Maximum characters: 2000)
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Will your Institution pay any part of each members membership fee? *
What percent of each members fee will the institution pay? (0 - 100%) *





Your form submission WILL be encrypted using SSL to ensure your privacy.