PHLIER Fellow Application
All information in Section 1 is required. Information in Section 2 is optional.
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SECTION 1
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First Name: |
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Last Name: |
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Title: |
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Agency: |
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| Resume/CV: |
*pdf or word file only |
| WORK CONTACT INFORMATION |
Address1: |
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Address2: |
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City: |
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County: |
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State: |
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Zip: |
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Phone: |
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Fax: |
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Email: |
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| Professional licenses held (Please check all that apply, or None): |
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Health Officer
Registered Environmental Health Specialist
Registered Nurse
CHES
None
Other
Other: (Please Check the 'Other' box above, or the application will not process)
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Number of years working in public health: |
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Number of years at current agency: |
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Briefly describe your present job responsibilities and leadership roles in your agency. |
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What professional public health/health associations are you a member of?
(please check all that apply or None): |
NJEHA
NJHOA
NJSOPHE
NJPHA
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NJAPHNA
NJSNA
NJSSNA
None
Other
Other: (Please Check the 'Other' box above, or the application will not process)
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Where do you see yourself professionally in five years and how do you anticipate that your participation in PHLIER will influence that goal? |
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Please summarize, in one or two paragraphs, one significant problem or opportunity facing public health in New Jersey. If you were a public health agency leader, what recommendations would you make? |
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SECTION 2
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| The following will help us to ensure a diverse class of PHLIER fellows: |
Gender: |
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Age: |
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| Ethnicity: |
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| Other, (Please Specify): |
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| More than one race (If yes, please specify): |
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*After submitting, please be patient as your application is processed. If you have any problems with this site, please contact Concetta Polonsky at 732-235-9703, caporrco@umdnj.edu
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