*First Name:

*Last Name:

*Credentials:

*Title:

*Organization:

Preferred Contact Information:

*Address:

*Address:

*City:

*State:

*Zip:

*Phone:

*E-mail:

Are you a:

New member
Renewing member

Primary Function:

Performance Improvement
Case Management 
HMO
Managed Care
Medical Records
Risk Management
Other

Other    

*Are you:

A member of NAHQ?    Yes No
 

A Certified Professional of Healthcare Quality?    Yes No
 

Planning to take the CPHQ exam within the next year?    Yes No Not applicable

Areas of Interest:

Education Committee

Executive Board

Nominating Committee

Web development/maintenance

If you are interested in speaking on a topic of interest to healthcare quality professionals, please indicate the topic:

Do you want to be included in the HQPNJ website Member Directory in the Members Only area?    Yes No

Do you want to be included on the HQPNJ membership list which might be available to external organizations?    Yes No

Acceptance of Terms and Conditions

I have reviewed and acknowledge acceptance of the terms and conditions which includes the cancellation policy, insufficient check funds policy, and the credit card terms and conditions.

  Select One Yes, I agree to the terms and conditions

Payment options include: Credit card and check