Thank you for your interest in the SPIPA Cancer Advisory Committee! Please complete this application to participate in the Committee. We will respond to your application within 5 business days.

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1. First and Last Names (Required.)

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2. Mailing Address (Required.)

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3. Email Address (Required.)

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4. Phone Number (Required.)

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5. What is your preferred method of contact? (Required.)

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6. What are your pronouns?

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7. Are you a Tribal Member? (Required.)

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8. Do you work for a Tribe? (Required.)

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9. Which Tribe are you a member of or work for? (Required.)

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10. Which Cancer Advisory Committee Workgroup(s) are you interested in? (Required.)

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