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The
Consumer Provider Association
in
New Jersey
Application for Membership
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Print out this form, fill it out, and mail the completed
form and your dues to:
CPA-NJ
C/O MHANJ
88 Pompton Avenue, Suite 1
Verona, NJ
07044
Name:____________________________________________________________
Home
Address:_____________________________________________________
Home Phone:
(_____)_____________ County:
_______________________
It is okay to contact
me at work: yes ________ no _________
I would prefer to
receive mail at: home ______ work _______
Work Address:
_______________________________________________________
Work Phone: (_____)__________________ County: _______________________
E-mail Address: (if
applicable)__________________________________________
MEMBERSHIP
CATEGORIES:
Full Membership is open
to Consumer Providers working as paid employees, volunteers, students and
consumers seeking to become Consumer Providers. Full members will have voting
rights on issues that affect the CPA-NJ and public policy and advocacy
issues taken by the CPA-NJ, access to free CPA-NJ sponsored workshops and
conferences, and receive a copy of the CPA-NJ Newsletter.
Associate Membership is
open to non-consumer providers, other mental health professionals and
friends of consumer providers. Associate members will receive a copy of the
CPA-NJ newsletter, notification of CPA-NJ sponsored events and be kept
informed of the CPA-NJ’s public policy and advocacy positions.
Agency/Organization
Membership is open to agencies, organizations and associations that would
like to support the work of the CPA-NJ. Agency/ Organization members will
receive a copy of the CPA-NJ newsletter, notification of CPA-NJ sponsored
events, and be kept informed of the CPA-NJ’s public policy and advocacy
positions.
Annual Membership
Fees:
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Membership Type:
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Working Full Time
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Working Part Time
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Student , Volunteer, Seeking Employment
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Full Membership
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$25
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$10
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$10
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Associate Membership
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$25
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Agency/Organization
Membership
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$125
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I would like to join
the CPA-NJ as a:
Full Member:
- Working full time ___
- Working part time ___
- Student, volunteer,
consumer seeking employment ___
Associate Member: _____
Agency/Organization
Member: ______
Enclosed please find
my annual membership dues of:
___$10 __$25 ___$125
Please make checks
payable to the "MHANJ/CPA-NJ"
I would like to join
the CPA-NJ confidentially: _____yes _____no
(Joining the CPA-NJ
confidentially means that your name, identifying information, or picture
will not be used in association with any CPA-NJ activities, and that you
would receive mail from the CPA-NJ in envelopes that are unmarked, and that
any CPA-NJ related phone calls to you would not identify be identified as
such.)
Signature:
________________________________________ Date:____________
Name (please print):
_______________________________
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