Membership Application 2012
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Name |
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Home Address |
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________________________________________ |
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Home Phone
Cell Phone |
_______________________________________ ________________________________________ |
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Business Name |
________________________________________ |
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County |
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Address |
________________________________________ |
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Phone |
________________________________________ |
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Fax |
________________________________________ |
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________________________________________ |
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Job Title |
________________________________________ |
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Brief Job Description |
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Degrees Held |
________________________________________ |
Are you a member of NJSNA? Yes____ No____
Where do you want your mail sent? Business____ Home____
Dues
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Active Member $75.00 |
Associate Member $25.00 |
Make check payable to: NJAPHNA
Amount Enclosed_______________
New membership______ Renewal______
Status: Active______ Associate______
Have you ever received a NJAPHNA pin? _____Yes _____No (one pin per member)
Will you serve on a committee? Yes___ No___ (If yes, indicate committee.)
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___Continuing Education |
___Membership |
___Emergency Preparedness |
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___Communicable Disease |
___Chronic Disease |
___Nominations |
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___Practice Standards/Best Practices/Legislative |
___Maternal-Child Health |
___By-laws |
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___Website |
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Ad-hoc committees: _____Newsletter, _____Publicity, ______Historian
Remit dues payment to:
Cindie
Bella
PO Box 900
Morristown, NJ 07963
Cindie Bella, Membership
Chairperson
Phone: 973-631-5491
E:mail:
cbella@co.morris.nj.us
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