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* Name (First/Last):

*Company:
(if applicable)

*Street Address:

*City:

*State:

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Phone:

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I am...
(please select all that apply)

Patient/Survivor
Caregiver/Family Member/Friend
Healthcare Professional
Pharmaceutical Rep/Employee
Researcher
Member of the Media

How did you learn about PanCAN?
(please select one from list)

How did you learn about PanCAN from health professional from non-profit org. internet website web search literature newspaper magazine broadcast friend/family member other

Describe your selection
(ie. name of newspaper, website, etc.)

Information Packets:
(please select one)

General PanCAN Info/Donor Kit - Contains information about all PanCAN research, patient, community outreach and education, and public policy programs, as well as the Annual Report, current PanCAN newsletter, PanCAN awareness brochure and an overview of our giving options.

Pancreatic Cancer Educational Packet - Contains disease information and resources for a patient, caregiver or friends. Includes PanCAN booklet, An Overview of Pancreatic Cancer, basic information about pancreatic cancer, how to get organized after diagnosis, stories of hope and inspiration, and PanCAN newsletter.

Stay Informed
(Please select one or both)

Periodic mailing (snail mail) including the "Outreach" quarterly newsletter and notices about special events.
Periodic email updates about PanCAN events, news, etc.

PanCAN will not share your information with third parties. (Privacy Policy)

If you experience problems submitting this form, please contact webmaster@pancan.org or by calling toll free 877-272-6226.