Commission on Cancer
New Facility Identification Number (FIN) Request Form
Please read the Guidelines for
Facility Identification Number (FIN)
before completing this form.
Before requesting a new FIN, please review the FIN list available on the American College of Surgeons website to verify that your facility has not already been assigned a FIN at:
FIN List
*
Date of Request:
*
Facility Contact’s First Name:
*
Last Name:
*
Email Address:
*
Phone Number:
-
(e.g. 111) (e.g. 111-1111)
*
Healthcare Facility Name:
*
Facility Address:
*
City and State:
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Zip:
*
Phone Number:
-
(e.g. 111) (e.g. 111-1111)
*
Facility Web Site:
Please indicate the other services provided
on-site
(check all that apply):
Medical
Surgical
Oncology
Other:
characters remaining
*
Indicates Required Field