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Create Profile First Name* (to change first name call (574) 401-8111) Last Name* (to change last name call (574) 401-8111) Preferred Email* (to change email address call (574) 401-8111) Username (lowercase alphanumeric) * Password (type this twice please) * password strength indicator Additional Info Salutation (Dr, Miss, Mrs, Mr, Professor, etc.) * Contact Details Professional Credentials Title/Position Are you a Director, Administrator or Manager? * No Yes Professional Specialty * RN RT StudentFellowRegistered NurseNurse NavigatorRadiologic TechnologistTechnologist NavigatorOther NavigatorGenetic CounselorNurse PractitionerPhysician AssistantDoctor of MedicineDoctor of OsteopathicObstetrician/GynecologistBreast SurgeonMedical OncologistPathologistPlastic SurgeonRadiologistRadiation OncologistOther Department Facility Name * Facility Street Location Address * City * State * Zip * Country Preferred Mailing AddressAdd Facility/Department field if not a home address Department Name (if applicable) Facility Name (if applicable) Street Address * City * State * Zip * Country Business Numbers for General Public/Clients. Published to facility and vendor directories for the public General Public Tel # (Required for Facility Memberships) General Public Email (Required for Facility Memberships) Fax Website Direct Numbers of Applicant Preferred Tel # Alternate Tel# Alternate Email Identify area(s) about which you would be willing to share your expertise (Hold control key down to select more than one) -- Select Here --Policy and Procedures ManualStaff Roles and Job DescriptionsAdministrative SoftwareTracking SoftwareBreast Center Physical SettingsStarting a Breast CenterExpanding a Breast Center to a Women's CenterMarketing TechniquesMachinery and EquipmentPurchase/FeasibilityMerging Facilities/Buyouts - Patient ImpactMerging Facilities/Buyouts - AdMinistrative/Operation ImpactClinical Pathway DevelopmentMobile MammographyPatient Educational ResourcesLymphedema ProgramsHigh Risk ProgramsOutreach ProgramsClinical TrialsBreast ReconstructionBreast AugmentationNutritional Counseling/InformationPsycho-social services/programs Business Description Please provide a description of your business. (I.e., services/products offered) The description you provide will be included on your Internet listing. You may attach or e-mail copy if more space is needed. Membership Networking Would you be willing to prepare an article or be interviewed and have our writer prepare an article about your breast center or its programs to be included in a future copy of the NCBC newsletter, the Breast Center Bulletin ? (Hold control key down to select more than one) * -- Select Here --YesNo From time to time we offer informational product information that we share and a bi-weekly Newsletter for our members. If you prefer not to receive these email, please un-check this box From time to time we offer informational product information that we share and a bi-weekly Newsletter for our members. 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