PERSONAL EXPOSURE REPORTING REIMBURSEMENT FORM
Pay the $12 subscription fee up front, and as a member in good standing of PFANJ, the fee will be reimbursed to you by the state association. ***Please forward the receipt to treasurer@newjerseyfirefighters.org***

**THIS FORM MUST BE COMPLETED TO RECEIVE YOUR REIMBURSEMENT & THE RECEIPT MUST BE EMAILED TO THE ABOVE ADDRESS BEFORE ANY PAYMENT IS SENT OUT**
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FIRST NAME: *
LAST NAME: *
EMAIL ADDRESS: *
PHONE NUMBER: *
LOCAL #: *
MAILING ADDRESS
STREET ADDRESS: *
TOWN: *
STATE: *
ZIP CODE: *
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