Membership Applying Organization:City/State:* City State / Province / Region Website: Proposed Roundtable Representative Name: First Last Representative Position/Title:Representative Email: Second Representative Name (optional): First Last Second Representative Position/Title (optional):Second Representative Email (optional): Additional email addresses to CC on emails (optional): Mission Statement:Preferred Mailing Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Business Telephone Number:Fax Number:Membership CategoriesPlease select your membership category (one only): Organizational/Institutional Individual (by invitation only) Corporate Please select from this list all labels that you feel best describe the organization you represent. (Check all that apply)* Academic Institution Cancer Center Cancer Coalition/Partnership (including Comprehensive Cancer Programs) City/County Health Department Community Health Center/FQHC Community Organization/Local Non-profit Consulting Group Employer Faith-based Organization Federal Agency Gastroenterology Practice Health Plan Hospital/Medical Center/Health System (hospital care, which can include primary care) Local/State Elected Leader Medical Professional Society (National) Medical Professional Society (State) National Non-profit Pharmaceutical/Medical Test/Device Company Primary Care Association Primary Care Practice/System (primary care only) Quality Improvement Organization State Health Department Survivor-based Organization Tribal Organization Other What is the focus of your organization's colorectal cancer screening programming? (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 (Individual members, please provide a biography and/or CV):*Describe briefly how you or your organization/institution meets one or more of the following membership criteria Have a strong interest in reducing colorectal cancer morbidity and mortality Have special expertise in colorectal cancer information and research Have a special expertise in colorectal cancer prevention, early detection and treatment Have the ability to deliver CRC education Have the ability to deliver CRC screening services The Roundtable is committed to facilitating interaction and collaboration between members who are highly engaged in the fight against colorectal cancer. Please provide a description of your organization’s history (or if you are an individual member, your experience and expertise) 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 colorectal cancer control efforts?*If your organization measures or tracks colorectal cancer screening rates, please share your current or most recent colorectal cancer screening rate. Please also describe your targets or goals for this rate.If your organization does not measure or track colorectal cancer screening rates, please describe your goals related to increasing colorectal cancer screening.If you have links to relevant CRC resources that your organization would be willing to share with NCCRT members, please list them here:Which Task Groups are you interested in serving on? Please rank in order of preference, with 1 being the highest preference. (Primary Representative)To add additional Task Groups click the plus iconPreferenceTask Groups 1st Choice2nd Choice3rd Choice4th Choice5th Choice6th Choice7th Choice8th ChoiceCommunity Health CentersEvaluation & MeasurementFamily History & Early OnsetPolicy ActionProfessional Education & Practice ImplementationPublic Awareness & Social MediaQuality AssuranceOther Other:Which Task Groups are you interested in serving on? Please rank in order of preference, with 1 being the highest preference. (Second Representative, if applicable)To add additional Task Groups click the plus iconPreferenceTask Groups 1st Choice2nd Choice3rd Choice4th Choice5th Choice6th Choice7th Choice8th ChoiceCommunity Health CentersEvaluation & MeasurementFamily History & Early OnsetPolicy ActionProfessional Education & Practice ImplementationPublic Awareness & Social MediaQuality AssuranceOther Other:How did you learn about the NCCRT?