Industry Collaboration Team (ICT) Enrollment Form

Please complete the Industry Collaboration Team (ICT) Enrollment Form and complete payment to enroll or renew your ICT Membership

Organization Name

Membership Type

Platinum Membership - $50,000

Gold Membership - $20,000

For full description of membership benefits, go to https://www.gog.org/gog-partners/become-and-industry-collaborator/

Main Membership Contact Information

First Name *

Last Name *

Degree

Title

Street Address *

Country *

State / Province *

City *

Postal / Zip Code *

Phone *

Fax

Email *

Administrative Assistant Contact Information

First Name

Last Name

Email

Meeting Planning Contact Information

Please provide the contact information for the team member that is responsible for meeting planning at your organization. This will be the person that the GOG staff will reach out to directly to schedule in person meetings.

Meetings Contact is the Same as Main Contact

Meetings Contact is Different than Main Contact

First Name *

Last Name *

Street Address *

Country *

State / Province *

City *

Postal / Zip Code *

Email *

Phone *

ICT Member Profile

Please provide a short corporate profile that will be listed on the GOG Website

Organization Website

Please upload a high resolution company logo (jpg, png or gif file)

Maximum file size: 134.22MB

If you are human, leave this field blank.

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Industry Collaboration Team (ICT) Enrollment Form

Main Membership Contact Information

Administrative Assistant Contact Information

Meeting Planning Contact Information

ICT Member Profile