2008-2009 Membership Application
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* Member directory information
*First Name:
*Last Name:
*Credentials:
*Title:
*Organization:
Preferred Contact Information:
*Address:
*City:
*State:
*Zip:
*Phone:
*E-mail:
Are you a:
New member Renewing member
North (area code 973, 201,551, 862) South (area code 609 and 856) Central (area code 908, 732, and 848)
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
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
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