PO Box 2315, Cherry Hill, NJ 08034-0179

Please Print Form & Mail Application .... .... website: www.njccr.org ....Questions?

Name: _____________________________________________________________________________________

Address: ___________________________________________________________________________________

Address: ___________________________________________________________________________________

City: ______________________________________________________________________________________

County: ___________________________________ State: ________ Zip: _____________________

Phone: _____________________________ wwwwwFax: _________________________________

E-mail: _________________________________________________________________________________

Please enroll me as a member in NJCCR as follows:

[ ] Full National (CRC or ACFC: select one below) and NJCCR (State) membership (includes full website
access, state and national newsletters, access to meetings and pro-se workshops)

[ ]... $90.00 ...NJCCR and CRC - Council for Children's Rights (www.goCRC.com) @ $50.00 (2006)

[ ]... $65.00....NJCCR and ACFC - American Coalition for Father's and Children (www.ACFC.org) @ $25 .00 (2006)

[ ] State membership only at $40.00/year (2006)--includes full website access,
state newsletter, access to NJCCR sponsored meetings, seminars and pro-se workshops.

[ ] Supporting member at $25.00/year (2006)

Enclosed is my check or money order in the amount of $__________, payable to “ NJCCR “.

Signature: _________________________________________________ Date: ___________________