EmailMeForm
North Central Region Field Operations Intake Form
Please note: Only current year and previous 2 years data are available in Salesforce.
Unique ID
Region
North Central Region
North Central Region
Area/Market
*
Please select
Michigan Area
Indiana Area
Illinois Area
Northern Ohio Area
Southwestern Ohio and Northern Kentucky Area
Central Ohio and West Virginia
Tennessee Area
Kentucky 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.
