Print out this form, fill it out, and mail the completed form and your dues to:

CPA-NJ/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:

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): _______________________________