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Summary: Ambassadors for Cancer Research: Today's Leaders Facilitating Tomorrow's Discoveries
QUESTIONNAIRE
If mailing is to be sent to only one person, you only need to complete this top section
Please print your name:
Prefix ____ First Name___________ Middle Name __________ Last Name___________ Suffix________
Please print your name exactly as you would like your mailing envelopes to be addressed to you:
__________________________________________________________________________________________
Please print your address _____________________________________ _______________
Street Apt. # if appropriate
_____________________________________ California _________
City ZIP CODE
Phone number_____________________ Birth date __________ Ethnicity ________________
How did you learn about the Ambassadors Program?_____________________________________________________
_______________________________________________________________________________________________
We may test e-mail as a way of sharing information. If you have an e-mail address, please include it if it would be an
acceptable way for you to receive our information.
___________________________________________________________
Please sign to indicate that you wish to be included in the Ambassadors Program:
If mail is to be addressed to two people, please include the second person's information and signature here
Please print you name here:
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