Thank you for your interest in receiving reimbursement for your NAADAC Associate Membership. To be considered for reimbursement, you must work or volunteer in a DMHAS funded initiative. Please complete and submit this online application for the consideration and reimbursement for the NAADAC Associate Membership application fee. Funding for this opportunity is made available through the New Jersey Department of Human Services, Division of Mental Health and Addiction Services State Opioid Response grant.

If you have any questions, please contact Janine Fabrizio at 732-367-0611 or Janine@njpn.org. 
Contact Information

Question Title

* 1. Full Name:

Question Title

* 2. Home Address:

Question Title

* 3. City, State, Zip Code:

Question Title

* 4. Phone Number:

Question Title

* 5. Email Address:

Work Information
As it relates to your Peer Recovery Specialist Certification

Question Title

* 6. Organization/Agency:

Question Title

* 7. Is your organization/agency DMHAS-licensed?

Question Title

* 8. Program you are currently working in (choose one):

Question Title

* 9. Please select Peer Trainings you have completed with NJPN:

Reimbursement Information

Question Title

* 10. Please provide your NAADAC Associate Membership number:

For consideration on the application, please upload a copy of the following documentation:

Question Title

* 11. Receipt indicating payment was made:

PDF file types only.
Choose File

Question Title

* 12. Completed W9 form. A blank copy of the W9 form can be found here: https://www.irs.gov/pub/irs-pdf/fw9.pdf

PDF file types only.
Choose File
Thank you for your submission.

T