NJUMP Membership Please enable JavaScript in your browser to complete this form.Title *Dr.Ms.Mr.Mrs.Prof.Name *FirstLastAddressAddress Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMobile Phone *United States +1United States+1United Kingdom+44Afghanistan+93Albania+355Algeria+213American Samoa+1Andorra+376Angola+244Anguilla+1Antigua & Barbuda+1Argentina+54Armenia+374Aruba+297Ascension Island+247Australia+61Austria+43Azerbaijan+994Bahamas+1Bahrain+973Bangladesh+880Barbados+1Belarus+375Belgium+32Belize+501Benin+229Bermuda+1Bhutan+975Bolivia+591Bosnia & Herzegovina+387Botswana+267Brazil+55British Indian Ocean Territory+246British Virgin Islands+1Brunei+673Bulgaria+359Burkina Faso+226Burundi+257Cambodia+855Cameroon+237Canada+1Cape Verde+238Caribbean Netherlands+599Cayman Islands+1Central African Republic+236Chad+235Chile+56China+86Christmas Island+61Cocos (Keeling) Islands+61Colombia+57Comoros+269Congo - Brazzaville+242Congo - Kinshasa+243Cook Islands+682Costa Rica+506Croatia+385Cuba+53Curaçao+599Cyprus+357Czechia+420Côte d’Ivoire+225Denmark+45Djibouti+253Dominica+1Dominican Republic+1Ecuador+593Egypt+20El Salvador+503Equatorial Guinea+240Eritrea+291Estonia+372Eswatini+268Ethiopia+251Falkland Islands+500Faroe Islands+298Fiji+679Finland+358France+33French Guiana+594French Polynesia+689Gabon+241Gambia+220Georgia+995Germany+49Ghana+233Gibraltar+350Greece+30Greenland+299Grenada+1Guadeloupe+590Guam+1Guatemala+502Guernsey+44Guinea+224Guinea-Bissau+245Guyana+592Haiti+509Honduras+504Hong Kong SAR China+852Hungary+36Iceland+354India+91Indonesia+62Iran+98Iraq+964Ireland+353Isle of Man+44Israel+972Italy+39Jamaica+1Japan+81Jersey+44Jordan+962Kazakhstan+7Kenya+254Kiribati+686Kosovo+383Kuwait+965Kyrgyzstan+996Laos+856Latvia+371Lebanon+961Lesotho+266Liberia+231Libya+218Liechtenstein+423Lithuania+370Luxembourg+352Macao SAR China+853Madagascar+261Malawi+265Malaysia+60Maldives+960Mali+223Malta+356Marshall Islands+692Martinique+596Mauritania+222Mauritius+230Mayotte+262Mexico+52Micronesia+691Moldova+373Monaco+377Mongolia+976Montenegro+382Montserrat+1Morocco+212Mozambique+258Myanmar (Burma)+95Namibia+264Nauru+674Nepal+977Netherlands+31New Caledonia+687New Zealand+64Nicaragua+505Niger+227Nigeria+234Niue+683Norfolk Island+672North Korea+850North Macedonia+389Northern Mariana Islands+1Norway+47Oman+968Pakistan+92Palau+680Palestinian Territories+970Panama+507Papua New Guinea+675Paraguay+595Peru+51Philippines+63Poland+48Portugal+351Puerto Rico+1Qatar+974Romania+40Russia+7Rwanda+250Réunion+262Samoa+685San Marino+378Saudi Arabia+966Senegal+221Serbia+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1Slovakia+421Slovenia+386Solomon Islands+677Somalia+252South Africa+27South Korea+82South Sudan+211Spain+34Sri Lanka+94St. Barthélemy+590St. Helena+290St. Kitts & Nevis+1St. Lucia+1St. Martin+590St. Pierre & Miquelon+508St. Vincent & Grenadines+1Sudan+249Suriname+597Svalbard & Jan Mayen+47Sweden+46Switzerland+41Syria+963São Tomé & Príncipe+239Taiwan+886Tajikistan+992Tanzania+255Thailand+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad & Tobago+1Tunisia+216Turkey+90Turkmenistan+993Turks & Caicos Islands+1Tuvalu+688U.S. Virgin Islands+1Uganda+256Ukraine+380United Arab Emirates+971United Kingdom+44United States+1Uruguay+598Uzbekistan+998Vanuatu+678Vatican City+39Venezuela+58Vietnam+84Wallis & Futuna+681Western Sahara+212Yemen+967Zambia+260Zimbabwe+263Åland Islands+358Personal Email *ProfessionMedical DoctorDoctor of OsteopathyPhysicians AssistantNurse PractitionerRegistered NurseDoctor of Veterinary MedicinePharmDOther (Please specify in "Specialty" below)SpecialtyAcupunctureAddiction MedicineAddiction PsychiatryAddiction and Substance Abuse CounselingAdolescent PsychologyAdvanced Heart Failure & Transplant CardiologyAerospace MedicineAllergy & ImmunologyAlternative CareAnatomic & Clinical PathologyAnatomic PathologyAnesthesiologyAnesthesiology AssistantArt TherapyAssisted LivingAssistive TherapyAthletic TrainingAttendant CareAudiologyAudiology AssistantBariatric MedicineBariatric SurgeryBehavior AnalysisBlood Banking & Transfusion MedicineBrain Injury MedicineCardiologyCardiovascular TechnologyChemical PathologyChild & Adolescent PsychiatryChild Abuse PediatricsChiropracticClinical Cardiac ElectrophysiologyClinical Exercise PhysiologyClinical InformaticsClinical LipidologyClinical NeurophysiologyClinical PathologyClinical PharmacologyClinical PsychologyColorectal SurgeryCommunity Health WorkCongenital Cardiac SurgeryCosmetic, Plastic & Reconstructive SurgeryCounselingCritical Care MedicineCritical Care SurgeryCytopathologyDance TherapyDarkroom TechnologyDental HygieneDentistryDermatologyDermatopathologyDevelopmental TherapyDevelopmental-Behavioral PediatricsDiagnostic Laboratory & Dermatologic ImmunologyDiagnostic RadiologyDiagnostic Ultrasound ImagingDieteticsEar, Nose, and ThroatElectrodiagnostic MedicineEmergency Medical Technology (EMT)Emergency MedicineEndocrinology, Diabetes & MetabolismEndodonticsFamily MedicineFemale Pelvic Medicine & Reconstructive SurgeryForensic PathologyForensic PsychiatryGastroenterologyGeneral Dentistry (Dental Assistant)General SurgeryGenetic CounselingGeneticsGeriatric MedicineHealth EducationHealthcare CoordinationHearing & Speech TherapyHearing InstrumentsHematologyHematopathologyHepatologyHolistic MedicineHome Health (Aide)HomeopathyHospice & Palliative MedicineHospital MedicineImmunopathologyInfectious Disease MedicineInternal MedicineInterventional CardiologyLabor Coaching (Doula)Laboratory Management TechnologyLaboratory MedicineLactation ConsultingLegal MedicineMarriage & Family TherapyMassage TherapyMastectomy FittingMaternal-Fetal MedicineMechanotherapyMedical EditingMedical EthicsMedical ExaminerMedical InformaticsMedical MicrobiologyMedical PhysicsMedical TechnologyMedical ToxicologyMental HealthMidwiferyMolecular Genetic PathologyMusic TherapyNaprapathyNaturopathyNeonatal MedicineNephrologyNeurodevelopmental DisabilitiesNeurogeneticsNeurologyNeuromusculoskeletal MedicineNeuropathologyNeuropsychologyNeuroradiologyNeurosurgeryNeurotologyNuclear MedicineNuclear RadiologyNurse AnesthesiologyNursing (Clinical Nurse Specialist)Nursing (Nurse Practitioner)Nursing (Registered Nurse)Nursing ServicesObstetrics & GynecologyOccupational & Physical TherapyOccupational MedicineOccupational TherapyOccupational Therapy AssistantOcularistryOncologyOphthalmic TechnologyOphthalmologyOphthalmic AssistantOptometryOptometry AssistantOptometry TechnologyOral & Maxillofacial PathologyOral & Maxillofacial RadiologyOral & Maxillofacial SurgeryOrthodontics & Dentofacial OrthopedicsOrthopedic Hand SurgeryOrthopedic Spine SurgeryOrthopedic SurgeryOrthopticsOrthotic FittingOtherPain MedicinePathology TechnologyPediatric Allergy & ImmunologyPediatric AnesthesiologyPediatric CardiologyPediatric Cardiothoracic SurgeryPediatric ChiropracticPediatric Critical Care MedicinePediatric DentistryPediatric DermatologyPediatric Diagnostic Laboratory ImmunologyPediatric DieteticsPediatric Emergency MedicinePediatric EndocrinologyPediatric GastroenterologyPediatric Hematology & OncologyPediatric Hospice & Palliative MedicinePediatric Infectious Disease MedicinePediatric Medical GeneticsPediatric Medical ToxicologyPediatric MedicinePediatric NephrologyPediatric Neurodevelopmental DisabilitiesPediatric NeurologyPediatric NeurosurgeryPediatric NursingPediatric Nursing (Nurse Practitioner)Pediatric Occupational TherapyPediatric OphthalmologyPediatric OptometryPediatric Orthopedic SurgeryPediatric Otolaryngology (Ear, Nose & Throat)Pediatric PathologyPediatric Physical TherapyPediatric Plastic SurgeryPediatric PulmonologyPediatric RadiologyPediatric RheumatologyPediatric Sleep MedicinePediatric Sports MedicinePediatric SurgeryPediatric Transplant HepatologyPediatric UrologyPediatricsPediatrics Physical Medicine & RehabilitationPeriodonticsPersonal Care AttendancePersonal Emergency Response AttendancePharmaceutical MedicinePharmacologyPharmacotherapyPharmacyPharmacy Clinician ServicesPhlebologyPhysical Medicine & RehabilitationPhysical TherapyPhysical Therapy (Physical Therapy Assistant)Physician Assistant (PA)Podiatric SurgeryPodiatryPodiatry (Podiatry Assistant)Poetry TherapyPractical Nursing (Licensed Practical Nurse)Preventive MedicineProstheticsProsthetics & OrthoticsPsychiatryPsychosomatic MedicinePsychotherapyPublic Health & General Preventive MedicinePulmonary DiseasePulmonary Function TechnologyRadiation OncologyRadioisotopic PathologyRadiologic TechnologyRadiologyRadiology (Practitioner Assistant)Recreation TherapyReflexologyReproductive Endocrinology & InfertilityResearchRespiratory TherapyRheumatologyRural MedicineSleep MedicineSocial WorkSpa MedicineSpeech-Language PathologySpinal Cord Injury MedicineSports MedicineSurgical (Selective) PathologySurgical AssistanceThoracic SurgeryTransplant HepatologyTransplant SurgeryUndersea & Hyperbaric MedicineUrgent Care MedicineUrologyVascular & Interventional RadiologyVascular MedicineVascular NeurologyVascular SurgerySpecialty Other *Employer (Optional)Employer Address (Optional)Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail Address (work) optional *Work Phone Number (optional)United States +1United States+1United Kingdom+44Afghanistan+93Albania+355Algeria+213American Samoa+1Andorra+376Angola+244Anguilla+1Antigua & Barbuda+1Argentina+54Armenia+374Aruba+297Ascension Island+247Australia+61Austria+43Azerbaijan+994Bahamas+1Bahrain+973Bangladesh+880Barbados+1Belarus+375Belgium+32Belize+501Benin+229Bermuda+1Bhutan+975Bolivia+591Bosnia & Herzegovina+387Botswana+267Brazil+55British Indian Ocean Territory+246British Virgin Islands+1Brunei+673Bulgaria+359Burkina Faso+226Burundi+257Cambodia+855Cameroon+237Canada+1Cape Verde+238Caribbean Netherlands+599Cayman Islands+1Central African Republic+236Chad+235Chile+56China+86Christmas Island+61Cocos (Keeling) Islands+61Colombia+57Comoros+269Congo - Brazzaville+242Congo - Kinshasa+243Cook Islands+682Costa Rica+506Croatia+385Cuba+53Curaçao+599Cyprus+357Czechia+420Côte d’Ivoire+225Denmark+45Djibouti+253Dominica+1Dominican Republic+1Ecuador+593Egypt+20El Salvador+503Equatorial Guinea+240Eritrea+291Estonia+372Eswatini+268Ethiopia+251Falkland Islands+500Faroe Islands+298Fiji+679Finland+358France+33French Guiana+594French Polynesia+689Gabon+241Gambia+220Georgia+995Germany+49Ghana+233Gibraltar+350Greece+30Greenland+299Grenada+1Guadeloupe+590Guam+1Guatemala+502Guernsey+44Guinea+224Guinea-Bissau+245Guyana+592Haiti+509Honduras+504Hong Kong SAR China+852Hungary+36Iceland+354India+91Indonesia+62Iran+98Iraq+964Ireland+353Isle of Man+44Israel+972Italy+39Jamaica+1Japan+81Jersey+44Jordan+962Kazakhstan+7Kenya+254Kiribati+686Kosovo+383Kuwait+965Kyrgyzstan+996Laos+856Latvia+371Lebanon+961Lesotho+266Liberia+231Libya+218Liechtenstein+423Lithuania+370Luxembourg+352Macao SAR China+853Madagascar+261Malawi+265Malaysia+60Maldives+960Mali+223Malta+356Marshall Islands+692Martinique+596Mauritania+222Mauritius+230Mayotte+262Mexico+52Micronesia+691Moldova+373Monaco+377Mongolia+976Montenegro+382Montserrat+1Morocco+212Mozambique+258Myanmar (Burma)+95Namibia+264Nauru+674Nepal+977Netherlands+31New Caledonia+687New Zealand+64Nicaragua+505Niger+227Nigeria+234Niue+683Norfolk Island+672North Korea+850North Macedonia+389Northern Mariana Islands+1Norway+47Oman+968Pakistan+92Palau+680Palestinian Territories+970Panama+507Papua New Guinea+675Paraguay+595Peru+51Philippines+63Poland+48Portugal+351Puerto Rico+1Qatar+974Romania+40Russia+7Rwanda+250Réunion+262Samoa+685San Marino+378Saudi Arabia+966Senegal+221Serbia+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1Slovakia+421Slovenia+386Solomon Islands+677Somalia+252South Africa+27South Korea+82South Sudan+211Spain+34Sri Lanka+94St. Barthélemy+590St. Helena+290St. Kitts & Nevis+1St. Lucia+1St. Martin+590St. Pierre & Miquelon+508St. Vincent & Grenadines+1Sudan+249Suriname+597Svalbard & Jan Mayen+47Sweden+46Switzerland+41Syria+963São Tomé & Príncipe+239Taiwan+886Tajikistan+992Tanzania+255Thailand+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad & Tobago+1Tunisia+216Turkey+90Turkmenistan+993Turks & Caicos Islands+1Tuvalu+688U.S. Virgin Islands+1Uganda+256Ukraine+380United Arab Emirates+971United Kingdom+44United States+1Uruguay+598Uzbekistan+998Vanuatu+678Vatican City+39Venezuela+58Vietnam+84Wallis & Futuna+681Western Sahara+212Yemen+967Zambia+260Zimbabwe+263Åland Islands+358Social Media Handle (optional): FacebookSocial Media Handle (optional): InstagramAnything else you’d like us to know:MEDICAL ADVISORY BOARDYes, 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. Submit Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Street Address *City *State *NJALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYZip Code *0 of 5 max characters.PhoneUnited States +1United States+1United Kingdom+44Afghanistan+93Albania+355Algeria+213American Samoa+1Andorra+376Angola+244Anguilla+1Antigua & Barbuda+1Argentina+54Armenia+374Aruba+297Ascension Island+247Australia+61Austria+43Azerbaijan+994Bahamas+1Bahrain+973Bangladesh+880Barbados+1Belarus+375Belgium+32Belize+501Benin+229Bermuda+1Bhutan+975Bolivia+591Bosnia & Herzegovina+387Botswana+267Brazil+55British Indian Ocean Territory+246British Virgin Islands+1Brunei+673Bulgaria+359Burkina Faso+226Burundi+257Cambodia+855Cameroon+237Canada+1Cape Verde+238Caribbean Netherlands+599Cayman Islands+1Central African Republic+236Chad+235Chile+56China+86Christmas Island+61Cocos (Keeling) Islands+61Colombia+57Comoros+269Congo - Brazzaville+242Congo - Kinshasa+243Cook Islands+682Costa Rica+506Croatia+385Cuba+53Curaçao+599Cyprus+357Czechia+420Côte d’Ivoire+225Denmark+45Djibouti+253Dominica+1Dominican Republic+1Ecuador+593Egypt+20El Salvador+503Equatorial Guinea+240Eritrea+291Estonia+372Eswatini+268Ethiopia+251Falkland Islands+500Faroe Islands+298Fiji+679Finland+358France+33French Guiana+594French Polynesia+689Gabon+241Gambia+220Georgia+995Germany+49Ghana+233Gibraltar+350Greece+30Greenland+299Grenada+1Guadeloupe+590Guam+1Guatemala+502Guernsey+44Guinea+224Guinea-Bissau+245Guyana+592Haiti+509Honduras+504Hong Kong SAR China+852Hungary+36Iceland+354India+91Indonesia+62Iran+98Iraq+964Ireland+353Isle of Man+44Israel+972Italy+39Jamaica+1Japan+81Jersey+44Jordan+962Kazakhstan+7Kenya+254Kiribati+686Kosovo+383Kuwait+965Kyrgyzstan+996Laos+856Latvia+371Lebanon+961Lesotho+266Liberia+231Libya+218Liechtenstein+423Lithuania+370Luxembourg+352Macao SAR China+853Madagascar+261Malawi+265Malaysia+60Maldives+960Mali+223Malta+356Marshall Islands+692Martinique+596Mauritania+222Mauritius+230Mayotte+262Mexico+52Micronesia+691Moldova+373Monaco+377Mongolia+976Montenegro+382Montserrat+1Morocco+212Mozambique+258Myanmar (Burma)+95Namibia+264Nauru+674Nepal+977Netherlands+31New Caledonia+687New Zealand+64Nicaragua+505Niger+227Nigeria+234Niue+683Norfolk Island+672North Korea+850North Macedonia+389Northern Mariana Islands+1Norway+47Oman+968Pakistan+92Palau+680Palestinian Territories+970Panama+507Papua New Guinea+675Paraguay+595Peru+51Philippines+63Poland+48Portugal+351Puerto Rico+1Qatar+974Romania+40Russia+7Rwanda+250Réunion+262Samoa+685San Marino+378Saudi Arabia+966Senegal+221Serbia+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1Slovakia+421Slovenia+386Solomon Islands+677Somalia+252South Africa+27South Korea+82South Sudan+211Spain+34Sri Lanka+94St. Barthélemy+590St. Helena+290St. Kitts & Nevis+1St. Lucia+1St. Martin+590St. Pierre & Miquelon+508St. Vincent & Grenadines+1Sudan+249Suriname+597Svalbard & Jan Mayen+47Sweden+46Switzerland+41Syria+963São Tomé & Príncipe+239Taiwan+886Tajikistan+992Tanzania+255Thailand+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad & Tobago+1Tunisia+216Turkey+90Turkmenistan+993Turks & Caicos Islands+1Tuvalu+688U.S. Virgin Islands+1Uganda+256Ukraine+380United Arab Emirates+971United Kingdom+44United States+1Uruguay+598Uzbekistan+998Vanuatu+678Vatican City+39Venezuela+58Vietnam+84Wallis & Futuna+681Western Sahara+212Yemen+967Zambia+260Zimbabwe+263Åland Islands+358Employment Information *Required to be collected by NJ ELEC Law*Occupation *UNEMPLOYEDHOMEMAKERRETIREDACCOUNTANT/AUDITORAGRICULTURALARCHITECT/SURVEYOR/PLANNERARMED SERVICESARTS/ENTERTAINMENTATHLETICSATTORNEYBUSINESS OWNERCONSTRUCTION TRADE/LABOR TRADECONSULTANTECONOMISTEDUCATION/PROFESSOR/TEACHERENGINEERFACTORY WORKER/MANUAL WORKERFINANCIAL SERVICES/BANKINGFIREFIGHTERHOSPITALITY/HOTEL/FOOD/BEVERAGEINFORMATION TECHNOLOGY/COMPUTER SCIENCEINSURANCELAW ENFORCEMENTLEGAL PROFESSIONALLOBBYIST/GOVERNMENT RELATIONSMANAGEMENT/ADMINISTRATOR/EXECUTIVEMANUFACTURINGMARKETING/PUBLIC RELATIONSMECHANIC/REPAIRERMEDIAMEDICAL PROFESSIONAL (NOT PHYSICIAN)OFFICE WORKERPHYSICIANPOLITICIANPUBLIC SECTORREAL ESTATERELIGIONRETAIL SALESSERVICES OCCUPATIONSOCIAL WORKERSTUDENTTRANSPORTATIONTRAVEL/TOURISMEmployer Name *Employer Street Address *Employer City *State *NJALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYZip *0 of 5 max characters.Donation Amount *Please enter an amount between $5 – $7200Donation Frequency *One TimeMonthlyCredit Card *CardName on CardTotal *$0.00NJ Legislative Voting District Comment or MessageSubmit