Global Colon Cancer Association Membership Application

Thank you for your interest in joining the global community of patient advocacy nonprofits and organizations that collectively work to end this disease and support those impacted by it.

This application is for nonprofits, NGOs, academic or research institutions, public health professionals, and advocates. For information on joining as a corporate member, please contact Nicole@globalcca.org.

Please fill out the below application and we will be in touch with you. For more information on membership, visit www.globalcca.org/members. Questions? Contact info@globalcca.org

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* 1. Please provide your contact information:

Name

Organization Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. If your organization name is different in English, please provide the name in English here:

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* 3. Acronym (if one is used, example: GCCA)

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* 4. Is your organization: (please select all that apply)

Non-profit entity (NGO) registered with your local government

For-profit entity

Other: Not registered as an organization or company (please describe in comments)

Patient advocacy group

Research institution

Academic institution

None of the above

If other, please describe:

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* 5. Is your organization:

National (Example: Chile)

Regional (Example: Latin America, North America, Europe)

International (Global)

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* 6. Disease Area:

Colorectal / bowel cancer

General Cancer, including colorectal / bowel cancer

Other (please specify)

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* 7. Year Established:

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* 8. Number of staff:

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* 9. Number of volunteers:

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* 10. Estimated number of patients, survivors and caregivers served in a year:

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* 11. Organization description including mission:

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* 12. Is your organization an umbrella group of member organizations?

Yes

If yes, please provide the number of member organizations:

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* 13. Provide information of the person who will be the contact for GCCA:

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 14. I confirm that the above information is accurate: (type your name and the date)

Name:

Date:

Global Colon Cancer Association Membership Application

Question Title

* 1. Please provide your contact information:

Question Title

* 2. If your organization name is different in English, please provide the name in English here:

Question Title

* 3. Acronym (if one is used, example: GCCA)

Question Title

* 4. Is your organization: (please select all that apply)

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* 5. Is your organization:

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* 6. Disease Area:

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* 7. Year Established:

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* 8. Number of staff:

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* 9. Number of volunteers:

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* 10. Estimated number of patients, survivors and caregivers served in a year:

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* 11. Organization description including mission:

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* 12. Is your organization an umbrella group of member organizations?

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* 13. Provide information of the person who will be the contact for GCCA:

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* 14. I confirm that the above information is accurate: (type your name and the date)

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* 15. Any additional information you'd like to share?