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Organization Application for Membership on the NAPRC
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1.
Organization Information
(Required.)
Name of Organization
Year Founded
Address
City/Town
State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
Website
Phone Number
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2.
Main Contact Information
(Required.)
Full Name
Title
Email Address
Phone Number
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3.
Executive Director
(Required.)
Full Name
Title
Email Address
Phone Number
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4.
Organization Mission Statement
(Required.)
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5.
Total Membership (#)
(Required.)
6.
Please describe any credentialing or accreditation activities (if applicable).
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.
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8.
Please describe how NAPRC membership will benefit your organization.
(Required.)
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9.
Please confirm that your organization is national in scope and serves a national membership.
(Required.)
Yes
No
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10.
Please describe how your organization actively addresses equity in cancer care.
(Required.)
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11.
Please indicate the organization’s primary areas of involvement in the field of oncology (check all that apply).
(Required.)
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
12.
Please attach your letter of interest in .PDF or .DOC, .DOCX format.
Choose File
No file chosen
13.
Information of individual completing this application (if different from main contact person).
Full Name
Position within the organization
Email Address
Phone Number
14.
Any additional supporting materials may be attached in this section.
Choose File
No file chosen
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.
