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<TITLE>Membership Application</TITLE></head>
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<p></p>
<CENTER><B>New Jersey Association of Public Health Nurse Administrators, Inc. </B></CENTER>
<P>Membership Application
<CENTER></CENTER>
<P>
<TABLE border=0>
<TBODY>
<TR>
<TD>Name</TD>
<TD>________________________________________</TD></TR>
<TR>
<TD>Home Address</TD>
<TD>________________________________________</TD></TR>
<TR>
<TD></TD>
<TD>________________________________________</TD></TR>
<TR>
<TD>Home Phone</TD>
<TD>________________________________________</TD></TR>
<TR>
<TD>Business Name</TD>
<TD>________________________________________</TD></TR>
<TR>
<TD>County</TD>
<TD>________________________________________</TD></TR>
<TR>
<TD>Address</TD>
<TD>________________________________________</TD></TR>
<TR>
<TD>Phone</TD>
<TD>________________________________________</TD></TR>
<TR>
<TD>Cell Phone</TD>
<TD>________________________________________</TD></TR>
<TR>
<TD>Fax</TD>
<TD>________________________________________</TD></TR>
<TR>
<TD>Email</TD>
<TD>________________________________________</TD></TR>
<TR>
<TD>Job Title</TD>
<TD>________________________________________</TD></TR>
<TR>
<TD>Brief Job Description</TD>
<TD>________________________________________</TD></TR>
<TR>
<TD>Degrees Held</TD>
<TD>________________________________________</TD></TR></TBODY></TABLE>
<HR>
Are you a member of NJSNA? Yes___ No___<BR>Where do you want your mail sent? Business___ Home___ 
<HR>

<CENTER><B>Dues</B><BR>
<TABLE width="75%" border=0>
<TBODY>
<TR>
<TD align=middle>Active Member $75</TD>
<TD align=middle>Associate Member </TD></TR></TBODY></TABLE>Make check payable to: NJAPHNA</CENTER>Amount Enclosed_______________<BR>New membership___ Renewal___<BR>Status: Active___ Associate___<BR>Have you ever received a NJAPHNA pin? ___Yes ___No (one pin per member) <BR>
<HR>
Will you serve on a committee? Yes___ No___ (If yes, indicate committee.) <BR>
<TABLE width="100%" border=0>
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<TD>___Continuing Education </TD>
<TD>___Membership </TD>
<TD></TD></TR>
<TR>
<TD>___Communicable Disease</TD>
<TD>___Chronic Disease </TD>
<TD></TD></TR>
<TR>
<TD>___Practice Standards/Legislative/Legal </TD>
<TD>___Maternal-Child Health </TD>
<TD>___By-laws </TD></TR></TBODY></TABLE><BR>
<P>Ad Hoc Committees 
<TABLE width="100%" border=0>
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<TD>___Emergency Preparedness</TD>
<TD>___Nominations </TD>
<TD>___Hospitality&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___Website&nbsp; </TD></TR></TBODY></TABLE><BR><BR>Send application to: <BR>Shu Chen Chiang, RN <BR>107 Albert Drive<BR>Clinton, NJ 08822<BR>(908) 806-4730<BR>schiang@co.hunterdon.nj.us </P>


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<nobr>|<a href="index.html">Welcome</A>|</nobr>

<nobr>|<a href="officers.html">Officers</A>|</nobr>

<nobr>|<a href="committees.html">Committees</A>|</nobr>

<nobr>|<a href="president.html">From the President's Desk</A>|</nobr>

<nobr>|<a href="meetings.html">Meetings</A>|</nobr>

<nobr>|<a href="nursesday.html">Nurse's Day</A>|</nobr>

<nobr>|<a href="dec2008.html">Holiday Meeting</A>|</nobr>

<nobr>|<a href="NJHSSupdates.html">NJHSS Updates</A>|</nobr>

<nobr>|<a href="Links1.html">Links</A>|</nobr>

<nobr>|<a href="webliography.html">Webliography</A>|</nobr>

<nobr>|<a href="education.html">Continuing Education</A>|</nobr>

<nobr>|<a href="representation.html">Representation</A>|</nobr>

<nobr>|<a href="membernews.html">Member News</A>|</nobr>

<nobr>|Application|</nobr>

<nobr>|<a href="pastpresidents.html">Past Presidents</A>|</nobr>

<nobr>|<a href="awards.html">Awards</A>|</nobr>

<nobr>|<a href="nomination.html">Nomination Form</A>|</nobr>

<nobr>|<a href="jobopportunities.html">Job Opportunities</A>|</nobr>

<nobr>|<a href="PHNJobDescription.html">PHN Job Description</A>|</nobr>

<nobr>|<a href="photo_album1.html">PHN Historical Photos</A>|</nobr>

<nobr>|<a href="contactus.html">Contact Us</A>|</nobr>
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