All information will be kept confidential and will only be released with your permission. The purpose of this registrar is to collect data and statistics to see if there is a higher incidence of breast cancer in Conejo Valley, CA; Simi Valley, CA; and San Fernando Valley, CA; as compared to the general population. I am also interested to see if there is an environmental cause in this area. Name: Street Address (1): Street Address (2): City, State, Zip: Phone Number(s): Fax Number(s): Email: Your name or loved one with cancer, date of Breast cancer diagnoses ,and age when diagnosed, death date if applicable Addresses and years of occupuncy in Simi Valley, Conejo Valley or San Fernando Valley. Family members diagnosed with cancer of any type and the city they reside in now.

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