NJUMP Membership – NJPHIPAC

Title *

Name *

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Last

Address

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Specialty

Specialty Other *

Employer (Optional)

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Social Media Handle (optional): Instagram

Anything else you’d like us to know:

MEDICAL ADVISORY BOARD

Yes, I would like more information about joining NJUMP’s Medical Advisory Board.
No, I am not interested in joining NJUMP’s Medical Advisory Board.

NJUMP’s Medical Advisory Board will be made up of select members of NJUMP. Duties may include, but are not limited to, check-in calls with NJPHIPAC board members, attending meetings and/or taking calls with elected officials/staff, signing off on correspondence from NJUMP, reviewing legislation NJUMP does or does not support.

Name *

First

Last

Email *

Street Address *

City *

State *

Zip Code *

Phone

Employment Information

*Required to be collected by NJ ELEC Law*

Occupation *

Employer Name *

Employer Street Address *

Employer City *

State *

Zip *

Donation Amount *

Please enter an amount between $5 – $7200

Donation Frequency *

Credit Card *

Card

Name on Card

Total *

$0.00

NJ Legislative Voting District

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