Membership Application

Applying Organization:

City/State:*

City State / Province / Region

Website:

Proposed Roundtable Representative Name:

First Last

Representative Email:

Representative Position/Title:

Second Representative Name (optional):

First Last

Second Representative Position/Title (optional):

Second Representative Email (optional):

Additional email addresses to CC on emails (optional):

Organization Mission Statement:

Preferred Mailing Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Telephone Number:

Fax Number:

Membership Categories

Please select your membership category (one only):

Organizational/Institutional

Corporate

Please select from this list all labels that you feel best describe the organization you represent. (Check all that apply)*

What is the scope of your organization's commitment to reduce the incidence of and mortality from lung cancer? (Check all that apply)*

National

Regional (parts of multiple states)

Local (one state or less than one state)

None

Please provide a brief description of your organization or institution*

Describe briefly how your organization/institution meets one or more of the following membership criteria

Have a strong interest in reducing lung cancer morbidity and mortality
Have outstanding expertise and reputation in lung cancer information and research
Have special expertise in any of the following: lung cancer risk reduction, early detection, diagnosis, staging, treatment, stigma, or patient support
Can deliver lung cancer education to individuals with lung cancer and/or providers
Can deliver lung cancer screening services
Can deliver smoking cessation/tobacco treatment services

The Roundtable is committed to facilitating interaction and collaboration between members who are highly engaged in the fight against lung cancer. Please provide a description of your organization’s history in this area.*

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 in lung cancer control efforts?*

If you have links to relevant lung cancer resources that your organization would be willing to share with NLCRT members on the NLCRT Resource Center, please list them here:

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NLCRT Membership

Membership Categories