Use your mouse to highlight the application information starting with the association name. Depending on the browser version you are using you need to either hit the printer drop down arrow or click on file, then hit print, when the print dialogue box opens choose <selection>, then print and only the text you highlighted will print producing a single page application.

New Jersey Fire Prevention & Protection Association

  PO Box 357, Springfield, NJ 07081-0357

2009 Individual Membership Dues

Amount:     $35.00

New Membership  r             Membership Renewal  r

Qualifications:  Any current employee of a New Jersey based:  State, County or Local Fire Marshal’s Office; or of a Fire Department or of a UFC Local Enforcing Agency shall be eligible as an Individual Member; or Anyone currently:  certified as a Fire Official, certified as a Fire Inspector, licensed as a Fire Subcode Official, or licensed as a Fire Protection Inspector shall be eligible as an Individual Member.

Name:                                                                         Title:                                                  

Organization:                                                                                                                       

Mailing Address:                                                                                                                 

City:                                                                 State:              Zip:                           

Phone:                                                Ext.                 Fax:                                      

Email:                                                                                    

UFC Certification #:                                                   UCC License #:                                         

County Association Name:                                                           

(If not a county association member fill in county declaration for Region Representation)

Are you an officer in the County Association:   r Yes  r No

Position Held:                                                          

Are you a member of ICC?   r Yes  r No                    ICC Membership #:                                    

If you are an ICC member do you wish to declare N.J.F.P.P.A. as your primary ICC Chapter?r Yes  r No

Applicant’s Signature:                                                                   

Association Office Use

Voucher/PO #:                                                 Check #:                               Date Received:                              

Date Approved:                                   Database Posted  r

Revised 11-2008