Organization Application for Membership on the NAPRC Question Title * 1. Organization Information Name of Organization Year Founded Address City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Website Phone Number Question Title * 2. Main Contact Information Full Name Title Email Address Phone Number Question Title * 3. Executive Director Full Name Title Email Address Phone Number Question Title * 4. Organization Mission Statement Question Title * 5. Total Membership (#) Question Title * 6. Please describe any credentialing or accreditation activities (if applicable). Question Title * 7. Please describe why your organization is seeking membership on the NAPRC, including specific examples of how your organization can add value to the NAPRC. Question Title * 8. Please describe how NAPRC membership will benefit your organization. Question Title * 9. Please confirm that your organization is national in scope and serves a national membership. Yes No Question Title * 10. Please describe how your organization actively addresses equity, diversity, and inclusion in cancer care. Question Title * 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 NAPRC standing committee Attend, and actively participate in, at least one in-person 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 NAPRC activities annually to your organization’s leadership and constituents Question Title * 12. Please attach your letter of interest in .PDF or .DOC, .DOCX format. PDF, DOC, DOCX file types only. Choose File Choose File No file chosen Remove File Please attach your letter of interest in .PDF or .DOC, .DOCX format. Question Title * 13. Information of individual completing this application (if different from main contact person). Full Name Position within the organization Email Address Phone Number Question Title * 14. Any additional supporting materials may be attached in this section. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Any additional supporting materials may be attached in this section. Question Title * 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. Submit Application