NB/PEI Public Health Association Membership Application Form - 2016
Please fill out the information below. This form will be submitted to the Board of Directors of NB/PEI Public Health Association.

Membership will not be granted until fees have been received. Please see below for instructions on how to submit your membership fees, or visit our website for more information on types of memberships (http://nbpeipublichealth.ca/membership.html).

Membership Application Status: *
Preferred Language of Correspondence: *
Gender: *
Required
Preferred Title: *
First Name: *
Your answer
Last Name: *
Your answer
Mailing Address: *
Please include the civic address, city, province, postal code, and country.
Your answer
Employer/Institution: *
Your answer
Job Title: *
Your answer
Primary Telephone Number: *
Your answer
Cell Phone Number:
Your answer
Fax Number:
Your answer
Primary E-mail Address: *
Please ensure this is entered correctly as it is our main means of connecting with you.
Your answer
Secondary E-mail Address:
Your answer
What areas of public health are you most interested in?
Ex: Aboriginal Health, Advocacy, Built Environment, Child and Family Health, Chronic Disease Prevention, Environmental Health, Health Literacy, Health Policy, Health Promotion, Health Research, Infectious Diseases, LGBTQ+ Health, Mental Health, Population Health, Public Health, Seniors Health, Sexual Health, Social Determinants of Health, etc.
Your answer
Would you be interested in joining any of the following Working Groups?
Please select all that apply.
Membership Type: *
If you would only like to be a member of the NB/PEI PHA, please select an option below. If you would also like to be a conjoint member of the Canadian Public Health Association, please access that form from their website: http://www.cpha.ca/uploads/provinces/join/2016/nb-pei_e.pdf
Membership Fee Payment Instructions:
Your membership application is not complete until we have received your payment. There are two options for paying your membership fee:

Option 1: e-Transfer
Step 1: Log in to your online banking platform and select the e-Transfer option.
Step 2: Please e-mail the fee associated with your membership type (see above) to nbpei.pha@gmail.com.
Step 3: Set the security question as "What are the last 4 digits of the primary phone number listed on your membership application?" and the answer as the last 4 digits of your primary phone number listed on this application.

Your information will be kept confidential. These applications are only reviewed by our Treasurer and the e-mail account is only accessed by certain board members on a need-to-know basis.

Option 2: Mail a Cheque
If you prefer, you can mail us a cheque made out to "CPHA NB/PEI Branch" for the fee amount associated with your membership type (see above section). Our mailing address is:

CPHA NB/PEI Branch
PO Box 30074
Prospect Plaza
Fredericton, NB
E3B 0H8

Connect With Us:
As a member, you will be added to our Newsletter mailing list. We encourage you to follow us on Twitter (www.twitter.com/CPHA_NBPEI), like us on Facebook (www.facebook.com/CPHA.NBPEI), visit our website (www.nbpeipublichealth.ca) or send us an e-mail with your thoughts on public health at nbpei.pha@gmail.com!
Thank You!
Thank you for your interest in the NB/PEI Public Health Association. We look forward to working with you to improve the health of those in our two provinces through advocacy, education, and leadership in public health!
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