Home Care Association of NJ Committee Registration Form

Member Name:_______________________________________________

Title:_____________________________________________________

Member Agency/ Company:______________________________________

Mailing Address:_____________________________­­­________________

_________________________________________________________

    Phone:______________________  Fax:_________________________          

   Email:____________________________________

I would like to participate on the following committee(s).  Please send me current meeting minutes or next meeting notice:

1.__________________________________________________________

2.__________________________________________________________

3.__________________________________________________________

(Note: If you would like more information about a committee before making a decision, feel free to call the staff person listed for the committee at 609/275-6100)

Please FAX this form to HOMECARENJ at 732-877-1101
Or mail to: The Home Care Association of NJ
485D Route 1 South, Suite 210
Iselin, NJ 08830