New Jersey Association of Public Health Nurse Administrators, Inc.
Membership Application

Name________________________________________
Home Address________________________________________
________________________________________
Home Phone________________________________________
Business Name________________________________________
County________________________________________
Address________________________________________
Phone________________________________________
Cell Phone________________________________________
Fax________________________________________
Email________________________________________
Job Title________________________________________
Brief Job Description________________________________________
Degrees Held________________________________________

Are you a member of NJSNA? Yes___ No___
Where do you want your mail sent? Business___ Home___
Dues
Active Member $75 Associate Member
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.)
___Continuing Education ___Membership ___Newsletter/Website
___Communicable Disease___Chronic Disease
___Practice Standards/Legislative/Legal ___Maternal-Child Health ___By-laws

Ad Hoc Committees
___Emergency Preparedness ___Nominations ___Hospitality


Send application to:
Shu Chen Chiang, RN
PO Box 2900
Flemington, NJ 08822
(908) 806-4730
schiang@co.hunterdon.nj.us

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