MEMBERSHIP APPLICATION Thank you for your interest in Society of Healthcare Risk Management of New Jersey for the year 2010-2011. The membership year runs from August 1, 2010 to July 31, 2011. Questions? Contact Us Please complete the online membership form below or print the application. Annual membership dues are $75.00. After January 1st, Half Year Membership Dues are $37.50. GENERAL INFORMATION NAME:  EMAIL:  CREDENTIALS:  TITLE:  ORGANIZATION:    HOMEADDRESS:  CITY:  STATE:  ZIP CODE:    WORKADDRESS:  CITY:  STATE:  ZIP CODE:    PRIMARY FUNCTION Risk Management Patient Safety Attorney Insurance Representative Performance Improvement Corporate Compliance Other ARE YOU A Member of ASHRM? A Certified Professional of Healthcare Risk Management? Planning to take the CPHRM Exam within the next year? AREAS OF INTEREST Education Committe Board of Directors Nominating Committee Web Development