EmailMeForm
Northeast Region Field Operations Intake Form
Please note: Only current year and previous 2 years data are available in Salesforce.
Unique ID
Region
Please select
Northeast Region
Area/Market
*
Please select
Eastern New England Area
Greater DC
Southern and Western New England Area
New York City Area
Greater Philadelphia Area
Greater Pittsburgh Area
Upstate New York Area
Your Email Address
*
firstname.lastname@cancer.org
Name your request
*
Request Date (Today's Date)
MM
/
DD
/
YYYY
List Type
*
Event Committee
Event Survivor
Event General Participant
Event Team Captain
Event Sponsors
Event Team
If 'Other' Please Explain
Communication Type
Phone
Email
Mail
What is the request due date?
*
MM
/
DD
/
YYYY
Event Society Key(s)
*
What is your goal? What is the business purpose of this request? Be specific and include a call to action.
*
If this is an event request, please list the full name of the events as they appear in Salesforce. Example: Relay For Life of Gwinnett County CY17, Relay For Life of Gwinnett County CY18, etc. Also provide the State where the event is taking place.
*
Please submit any documents that you think will be informative or helpful in fulfilling the request. PLEASE DO NOT SUBMIT ANY FILES WITH CUSTOMER DATA.
For Compliance:
*
I am aware of ACS’s minimum necessary standard for data and understand that I am responsible for staying in compliance with the Society’s policies. Such as the ACS Acceptable Use Policy and Information Management Security Policy.
Will you be sharing this information with anyone outside of the American Cancer Society? (i.e. vendors, volunteers)
If so, please identify these individuals by name or role. If you are sharing with vendors, please provide contract number.
