Cancer Center Registration – Cleaning for a Reason

Do you run or work for a Cancer Center? Fill out the application below to receive free tear off note pads about Cleaning for a Reason’s free cleaning services to provide to your patients and visitors.

Please complete the following form and a member of our team will contact you.

Qualifications: Cancer centers must be located within the United States or Canada.

Are you currently battling cancer? If you are currently undergoing treatment for cancer, complete our Cancer Patient Application to apply for our services.

Cancer Center Registration

Name *

First

Last *

Last

Job Title

Organization Name

Email *

Work Phone *

Please include extension if applicable

Street Address *

City *

State/Province *

Zip/Postal Code

Country *

How did you hear about us?

Please define your service territory

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If you are human, leave this field blank.