Membership

2019 NJACCHO Membership Application

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Are you renewing your exisiting membership?:

Yes, or leave unchecked for no.

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Last Name:*

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Organization:

Address:

City:

State:

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Degrees/Certifications:

Size of Population Served:

NJACCHO Membership Dues:
(001) Organizational Membership - $ 250.00

NJ Recognized Local Public Health Department and affiliated public health professionals.

(002) Individual Member - $ 250.00

Health Officers with active license

(003) Active Member - Retired - $ 50.00

Health Officer with active license, retired in good standing

(004) Affiliate Member - $ 75.00

Individual who is not eligible for Active membership

(005) Honorary Member - $ 0.00

Bestowed 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