NJAMHAA Individual Membership Application
Dues must be paid with submission of application; otherwise, membership will not be activated. Thank you for your application and payment!

If you would like to download a PDF version of this application and mail it to the office, please go to: http://www.njamha.org/links/Individual_Membership_Application.pdf

Name
Your answer
Title
Your answer
Degree
Your answer
E-mail Address
Your answer
Address
Your answer
City
Your answer
State
Your answer
County
Your answer
Zip
Your answer
Telephone #
Your answer
Fax #
Your answer
Cell #
Your answer
Web Site
Your answer
Type of Professional
Area of Expertise
Required
Have you ever been disbarred from professional practice?
If you answered "yes" to above, please explain:
Your answer
Please list three references:
Reference 1:
Your answer
Reference 2:
Your answer
Reference 3:
Your answer
Please list reasons why you are joining NJAMHAA:
Your answer
How did you hear about NJAMHAA?
Your answer
If you were specifically referred by a NJAMHAA member, please provide the individual’s contact information (name, organization, address, phone and e-mail):
Your answer
Organizational affiliations:
Your answer
Please send your application with your payment of $250.00 membership dues for individual
membership or $100 membership dues for full-time students to:

Ksenia Lebedeva, Coordinator of Advocacy and Member Services
NJAMHAA
3635 Quakerbridge Bridge Road, Suite 35
Mercerville, NJ 08619

Checks can be made out to NJAMHAA. If you would like to pay by credit card (Visa or Master Card
only), please e-mail klebedeva@njamhaa.org for the credit card authorization form.

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