NJCUPSA Membership Application (Mail In Payment)

Date

Time

:HourMinutesAM/PM Option

Primary Applicant:

Applicant Name:*

PrefixFirst NameLast NameSuffix

Position:*

Institution:*

University/College/Firm

Email*

example@example.com

Work Phone:*

Cell Phone:*

Fax:

Business Address:*

Street Address

Street Address Line 2

CityState

Zip Code

Membership Categories

Institutional Member + up to (3) Associates — $300.00Institutional Member + up to (7) Associates — $400.00Institutional Member + up to (11) Associates — $500.00Affiliate Member — FreeAssociate Member — $25Supporting Member — $300.00

Signature of Renewing Member or Applicant*

Additional Associates

Number of Additional Associates*

Enter 0 - 11

ASSOCIATE (1) NAME:*

PrefixFirst NameLast NameSuffix

Associate (1) Position:*

Associate (1) Email*

example@example.com

Associate (1) Work Phone:*

Associate (1) Cell Phone:*

ASSOCIATE (2) NAME:*

PrefixFirst NameLast NameSuffix

Associate (2) Position:*

Associate (2) Email*

example@example.com

Associate (2) Work Phone:*

Associate (2) Cell Phone:*

ASSOCIATE (3) NAME:*

PrefixFirst NameLast NameSuffix

Associate (3) Position:*

Associate (3) Email*

example@example.com

Associate (3) Work Phone:*

Associate (3) Cell Phone:*

ASSOCIATE (4) NAME:*

PrefixFirst NameLast NameSuffix

Associate (4) Position:*

Associate (4) Email*

example@example.com

Associate (4) Work Phone:*

Associate (4) Cell Phone:*

ASSOCIATE (5) NAME:*

PrefixFirst NameLast NameSuffix

Associate (5) Position:*

Associate (5) Email*

example@example.com

Associate (5) Work Phone:*

Associate (5) Cell Phone:*

ASSOCIATE (6) NAME:*

PrefixFirst NameLast NameSuffix

Associate (6) Position:*

Associate (6) Email*

example@example.com

Associate (6) Work Phone:*

Associate (6) Cell Phone:*

ASSOCIATE (7) NAME:*

PrefixFirst NameLast NameSuffix

Associate (7) Position:*

Associate (7) Email*

example@example.com

Associate (7) Work Phone:*

Associate (7) Cell Phone:*

ASSOCIATE (8) NAME:*

PrefixFirst NameLast NameSuffix

Associate (8) Position:*

Associate (8) Email*

example@example.com

Associate (8) Work Phone:*

Associate (8) Cell Phone:*

ASSOCIATE (9) NAME:*

PrefixFirst NameLast NameSuffix

Associate (9) Position:*

Associate (9) Email*

example@example.com

Associate (9) Work Phone:*

Associate (9) Cell Phone:*

ASSOCIATE (10) NAME:*

PrefixFirst NameLast NameSuffix

Associate (10) Position:*

Associate (10) Email*

example@example.com

Associate (10) Work Phone:*

Associate (10) Cell Phone:*

ASSOCIATE (11) NAME:*

PrefixFirst NameLast NameSuffix

Associate (11) Position:*

Associate (11) Email*

example@example.com

Associate (11) Work Phone:*

Associate (11) Cell Phone:*

Please make check payable to
NJCUPSA and remit to:

NJCUPSA
1506 King George Lane
Toms River, NJ 08753

Type words you see.*