Membership Application

The following form will be used to gather information in order to process your membership application.

Be sure to complete the entire form.

NLCRT Membership

"*" indicates required fields

Proposed Roundtable Representative Name:
Second Representative Name (optional):
Preferred Mailing Address:

Membership Categories

Please select your membership category (one only):
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)*
  • 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