Suggested Reading Submission Form

Title of Book *

Author's Name *

Author's Credentials (if applicable)

Published Date (Requests for non-published books will not be accepted.) *

ISBN #: *

Where is the book available?

In which formats are the book available? *

Print

eReader

Audio

Other Other

Please provide a brief summary of the book. *

0/500 characters

Target Audience (check all that apply) *

Topic (check all that apply) *

How did you hear about LLS? *

Contact Information

We will reach out to you with next steps for submitting your book.

First Name *

Last Name *

Email Address *

Please confirm your email address. *

Phone Number *

Zip Code *

Would you like to receive emails about education and resources from LLS? *

Yes, please keep me up to date.

No, thank you.

I am a: *

If other, please specify.

What is your/the patient's date of diagnosis? (If applicable)

My or my loved one's diagnosis is (if applicable): *

Leukemia Disease Type *

Lymphoma Disease Type *

Myeloproliferative Neoplasms Disease Type *

Other Disease Type *

Type *