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New Jersey Prevention Health Education Network
Membership Form

In order for your agency to become a member of NJ PHEN, you must complete all items on this form and submit it. There are no fees for membership. If you have any questions about this form or NJ PHEN membership, please contact us.


Contact Person: Name:
Job Title:

Mailing Address:

Phone: - -
Check if you prefer not to have this number posted on the web

Fax: - -


Website Address:

Counties Served:

Organization Profile:
Number of Staff:  Full-Time: Part-Time: Volunteer:
(please include a brief description
of the types of services provided) 
Client Population: 
Area(s) of Expertise: 
Area(s) in which collaborative opportunities sought: 

Required Fields   

Department of Health

P. O. Box 360, Trenton, NJ 08625-0360
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Last Modified: Tuesday, 10-Jul-12 12:01:58