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Yes I want to join ACS CAN in the fight to make cancer a top national priority RELAY EVENT NAME MR MRS MS DR FIRST NAME MI LAST NAME SUFFIX SR JR III PROFESSIONAL DEGREE MD PhD HOME ADDRESS CITY STATE - ZIP CODE HOME PHONE W/ AREA CODE EMAIL ADDRESS MOST ACS CAN COMMUNICATION IS SENT VIA EMAIL. IF YOU DO NOT PROVIDE AN EMAIL ADDRESS YOU MAY NOT RECEIVE THOSE COMMUNICATIONS. A minimum contribution of 10 is required for membership 10 ACS CAN Member 250 Leader s Circle 500 Hero s Circle 100 Capitol Circle 1000 Champion s Circle Other Please choose a method of payment CASH CHECK TO AMERICAN CANCER SOCIETY CANCER ACTION NETWORK INC OR ACS CAN AMERICAN EXPRESS CREDIT CARD NO DISCOVER MASTERCARD VISA EXP. DATE MONTH YEAR SIGNATURE Please mail your gift along with this membership form to 128 Stonemark Lane Columbia SC 29210 Because we use your donations to support our citizen-based advocacy and lobbying efforts to end cancer contributions to the American Cancer Society Cancer Action Network Inc. are not taxdeductible. Yes I want to join ACS CAN in the fight to make cancer a top national priority RELAY EVENT NAME MR MRS MS DR FIRST NAME MI LAST NAME SUFFIX SR JR III PROFESSIONAL DEGREE MD PhD HOME ADDRESS CITY STATE - ZIP CODE HOME PHONE W/ AREA CODE EMAIL ADDRESS MOST ACS CAN COMMUNICATION IS SENT VIA EMAIL* IF YOU DO NOT PROVIDE AN EMAIL ADDRESS YOU MAY NOT RECEIVE THOSE COMMUNICATIONS* A minimum contribution of 10 is required for membership 10 ACS CAN Member 250 Leader s Circle 500 Hero s Circle 100 Capitol Circle 1000 Champion s Circle Other Please choose a method of payment CASH CHECK TO AMERICAN CANCER SOCIETY CANCER ACTION NETWORK INC OR ACS CAN AMERICAN EXPRESS CREDIT CARD NO DISCOVER MASTERCARD VISA EXP. DATE MONTH YEAR SIGNATURE Please mail your gift along with this membership form to 128 Stonemark Lane Columbia SC 29210 Because we use your donations to support our citizen-based advocacy and lobbying efforts to end cancer contributions to the American Cancer Society Cancer Action Network Inc* are not taxdeductible.

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