2025 NJACCHO/NJEHA Annual Conference Scholarship Application

2025 NJACCHO/NJEHA Annual Conference Scholarship Application
Full Name *
Current Date

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Alternative Phone Number

Area CodePhone Number
Email Address*
Please enter a valid email address
Are you a current member of NJEHA?*
Are you currently employed with a New Jersey Local, County, or State Health Department?*
If yes, please select which type.
Current Employer:
Please select any of the following licenses or certifications you currently hold:*

Registered Environmental Health SpecialistHealth OfficerCertified Health Educator SpecialistRegistered NurseN/AOther
Conference Scholarship Request?*
One Day Attendee Date of Attendance:

Sunday - March 2, 2025Monday - March 3, 2025Tuesday - March 4, 2025
Do you prefer a vegetarian meal? *
Do you require a gluten-free meal?*

Declaration
1. I confirm that all the information given in my application is true and accurate to the best of my knowledge, and that I have not deliberately omitted any relevant fact.

2. I understand that if I am found to have provided any false or inaccurate information in my application, (a) disbursement may be withheld; and (b) I will be obliged to refund NJEHA the total amount of monies that has already been paid to me.

3. I understand that NJEHA reserves the right to reject any application without providing verbal or written explanation
Signature of Applicant*

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Date*

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Date
Should be Empty:

2025 NJACCHO/NJEHA Scholarship Application