NJSHCA - Membership Application

New Jersey
Society for Healthcare
Consumer Advocacy

Membership Application

If you would like to become a member of the NJSHCA, please complete the following membership application:

Name:

Position/Title:

Department:

Name of Institution:

Address:

Address2:

City:

ST/Zip:

Business Phone:

Fax:

Email:

Membership:

Before 2/1/12
$175.00

After 2/1/12
$200.00

Status:

New

Renewal

Guests:

Effective 1/1/12 - (One time only)
guest fee: $50.00

Please make checks payable to NJSHCA
Mail payment to:: Linda M. Flanagan
Manager Patient Relations
Virtua Health
175 Madison Avenue, Mt. Holly, NJ 08060
phone (609) 914-6555
fax (609) 914-6557

URL: http://www.NJSHCA.org