State Affiliate Council Contact Form

This form should be completed by ASCO’s State Affiliates when changes in leadership occur throughout the year in order to keep the State Affiliate Council roster up-to-date. If you have any questions, please contact the State/Regional Affiliate Program team.

State Society Name *

Please select one *

President

State Affiliate Council Representative

Executive Director

Are they also the State Affiliate Council Representative? *

Yes

Name *

Designation *

Organization/Institution

Address *

Address 1 *

Address 2

City *

State *

ZIP code *

Phone Number *

Fax Number (If Applicable)

Email Address *

Term End Date

Leave this field blank

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