Organization Application for Membership on the NAPBC

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* 1. Organization Information

Name of Organization

Year Founded

Address

City/Town

State/Province

ZIP/Postal Code

Website

Phone Number

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* 2. Main Contact Information

Full Name

Title

Email Address

Phone Number

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* 3. Executive Director

Full Name

Title

Email Address

Phone Number

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* 4. Organization Mission Statement

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* 5. Total Membership (#)

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* 6. Please describe any credentialing or accreditation activities (if applicable).

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* 7. Please describe why your organization is seeking membership on the NAPBC, including specific examples of how your organization can add value to the NAPBC.

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* 8. Please describe how NAPBC membership will benefit your organization.

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* 9. Please confirm that your organization is national in scope and serves a national membership.

Yes

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* 10. Please describe how your organization actively addresses equity, diversity, and inclusion in cancer care.

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* 11. Please indicate the organization’s primary areas of involvement in the field of oncology (check all that apply).

Cancer registration and/or surveillance

Cancer patient care services

Patient education, support, advocacy organization

Cancer control and prevention efforts

Professional education in oncology

Oncology research

Clinical, professional organization with an oncology focus

If selected for membership, please evaluate your organization and its appointed representative’s ability to meet the following core expectations.

Serve a minimum, three-year term
Serve on, and actively participate in, at least one NAPBC standing committee
Attend, and actively participate in, at least one in-person Board meeting a year, which include the appointed committee and quarterly committee conference calls
Financially support your representative’s travel and lodging to the in-person meetings
Report on NAPBC activities annually to your organization’s leadership and constituents

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* 12. Please attach your letter of interest in .PDF or .DOC, .DOCX format.

PDF, DOC, DOCX file types only.

Choose File

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* 13. Information of individual completing this application (if different from main contact person).

Full Name

Position within the organization

Email Address

Phone Number

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* 14. Any additional supporting materials may be attached in this section.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 15. Please enter your eSignature below:

For questions, please contact Victoria Hernandez, Cancer Programs Administrator, at cpmembership@facs.org or via phone (312) 202-5209.