Question Title

* 1. Organization Information

Question Title

* 2. Main Contact Information

Question Title

* 3. Executive Director

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.

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). 

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

Question Title

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

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

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.

T