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National Cancer Survivors Day® Speakers Bureau Application
Please complete and return this form, along with your suggested roster listing, to be considered for publication in the online NCSD Speakers Bureau Roster.
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* Indicates required question
Email
*
Your email
Name
*
First and last name
Your answer
Address
*
Your answer
Email
*
Your answer
Phone number
*
Your answer
Website (if applicable)
Your answer
Twitter Username (if applicable)
Your answer
Facebook Page (if applicable)
Your answer
Instagram Username (if applicable)
Your answer
Roster Listing
*
Please provide your suggested description. Please
limit your description to 640 characters including spaces
(excluding contact information). The Foundation reserves the right to edit your listing for clarity and brevity.
Your answer
Do you handle scheduling and other arrangements yourself?
*
Yes
No
Required
Do you want to have organizations contact your agent to arrange speaking engagements?
*
Yes
No
N/A
Required
Agent Information (if applicable)
Name /Company:
Address:
City:
State:
Zip:
Phone #:
E-mail Address:
Web Address:
Your answer
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