NJEHA Conference and Meeting Honorarium

Instructions: Complete application legibly and in its entirety. Illegible or incomplete applications will be rejected. The Gary S. Strauss Scholarship Fund Conference Honorarium is available only to NJEHA Active Members in good standing. Submit completed application by the deadline of February 15th via email to Virgina Wheatley at: virginia.wheatley@doh.state.nj.us Successful applicants will be notified no later than February 22nd.

Name

First Name Last Name

Phone Number

Area Code Phone Number

Fax Number

Area Code Phone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Are you an Active Member (in good standing) of the New Jersey Environmental Health Association?

Yes No

Have you ever attendedthe NJEHA Annual Educational Conference in Atlantic City previously?

Yes No

Will your employer fund any or all of your NJEHA Conference attendance costs?

Yes No

List any civic groups,associations and/or other communityorganizations of which the Applicant is a member.

Attach a brief statement describing why you want to attend the NJEHA Conference.

Signature (Please Type Your Name in the Box that you agree to all terms and conditions.)

Members who are awarded the Gary S. Strauss Scholarship Fund Annual Conference Honorarium will be reimbursed AFTER they attend the conference and submit an article for publication in the NJEHA newsletter. Articles must be at least 150 words and are to be submitted to Virginia Wheatley at virginia.wheatley@doh.state.nj.us no later than May 1st.