Application for ACS NPCRT Membership - American Cancer Society National Prostate Cancer Roundtable

Applying Organization

Website

Representative Email:

Representative Position/Title:

Second Representative Position/Title (optional):

Second Representative Email (optional):

Additional email addresses to CC on emails (optional):

Organization Mission Statement:

Business Telephone Number:

Fax Number:

Membership Categories

Please provide a brief description of your organization or institution:(Required)

Individual members, please provide a biography and/or CV.

Describe briefly how you or your organization/institution meets one or more of the following membership criteria: (1) Have a strong interest in reducing prostate cancer morbidity and mortality, (2) Have special expertise in prostate cancer information and research, (3) Have a special expertise in prostate cancer prevention, early detection and treatment, (4) Have the ability to deliver prostate cancer education, (5) Have the ability to deliver prostate cancer care services:(Required)

The Roundtable is committed to facilitating interaction and collaboration between members who are highly engaged in the fight against prostate cancer. Please provide a description of your organization’s history (or if you are an individual member, your experience and expertise) in this area.(Required)

What does your organization specifically want to gain from Roundtable membership?

What specific expertise/experience does your group have to offer the Roundtable? How has your organization been a leader or innovator around prostate cancer?(Required)

If you have links to relevant resources that your organization would be willing to share with ACS NPCRT members, please list them here:

How did you learn about the ACS NPCRT? If you're working with an ACS staff member, please list their name.