NJEHA Harry H.R. Nicholas Award

NJEHA President’s Plaque - Nomination Form
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Please note: the nomination deadline is January 30th of each year.

To be eligible for the NJEHA President’s Plaque , a nominee must:

1. Be actively engaged in the field of public health; and

2. Have performed meritorious contributions on behalf of public and environmental health in New Jersey.

Please complete both pages of this form, and return it via email at info@njeha.org or mail it to

NJEHA at the address listed at the bottom of the page. Please print clearly.

___________________________________________________________________________
Nominee Name*
(as it should appear on plaque)
Title and Employer*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
E-mail
Submitted by:*
Title and Employer*
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
E-mail*
Describe the meritorious contributions on behalf of public and environmental health in New Jersey performed by your nominee. (If you prefer to upload your document from word please attach below)
Upload response here:

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