NJEHA Harry H.R. Nicholas Award

NEHA Certificate of Merit Award - Nomination Form
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Please note: the nomination deadline is March 31st of each year.

To be eligible for the NEHA Certificate of Merit award, a nominee must:

1. Be a member in good standing of the NJ Environmental Health Association;

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

3. Have performed meritorious contributions on behalf of environmental health in the past year.

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 environmental health performed by your nominee in the last year. (If you prefer to upload your document from word please attach below)
Upload response here:

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NEHA Certificate of Merit Award - Nomination Form