Membership 2021 NJACCHO Membership Application * indicates required field Are you renewing your exisiting membership?: Yes, or leave unchecked for no. Email:* Please leave this blank Please do not change this field Last Name:* First Name:* Organization: Address: City: State: Zip: Phone: Extension: Fax: Web page: Degrees/Certifications: Size of Population Served: Committees: The NJACCHO relies on its membership to remain active on issues that affect local health departments, so please volunteer to serve on a committee! Please place a check mark beside an area (or two, or more) where you can lend some assistance to the organization. Workgroups and Committees: By-Laws Maternal & Child Health Communicable Disease Legislation Chronic Illness & Disease Marketing, Membership & Fundraising Environmental Finance Emergency Preparedness Program Awards Program NJACCHO Membership Dues: (001) Organizational Membership - $ 250.00NJ Recognized Local Public Health Department and affiliated public health professionals. (002) Individual Member - $ 250.00Health Officers with active license (003) Active Member - Retired - $ 50.00Health Officer with active license, retired in good standing (004) Affiliate Member - $ 75.00Individual who is not eligible for Active membership (005) Honorary Member - $ 0.00Bestowed by Executive Committee upon review of application Payment: Check Purchase Order Message: For Purchase Order payments, please make payable to the New Jersey Association of County and City Health Officials, please send to: NJACCHO PO Box 6987 Freehold, NJ 07728