OMMH appreciates your assistance in helping us to update our database of Contacts. If you are new to our list, welcome! Please complete all items on the form. Note that all items marked with an asterisk () are required, and the system will not accept your entry if they are not completed. Thank you.

If you are unable to fill out this form online you can contact us as follows:
Office of Minority & Multicultural Health
John Fitch Plaza
PO Box 360Trenton, NJ 08625-0360
Phone: (609) 292-6962 Fax: (609) 292-8713

  Mailing List Update Form

1. Organization Name:
If a Branch/Chapter, Name:

2. Organization Type:

Minority Community-Based Organization (MCBO)Municipal Government
Hospital/ClinicEducational Institution
Church or Faith-Based Organization (FBO)Media
Federally Qualified Health Center (FQHC)Coalition, Alliance or Association
Health Professional AssociationFoundation
Health Insurance/Maintenance OrganizationAsylee, Refugee and/or Immigrant Services Agency
Health Care Provider OrganizationSupport Group
Elected OfficialCommunity Leader
Federal GovernmentSocial & Culture Organization
State GovernmentNJ Public Health Officer
County GovernmentInterested Individual
Other, Please specify:

3. Type of Services:

Diagnosis/TreatmentCommunity Outreach/Education
Screening/ReferralProfessional Education/Training
Other, Please specify:

4. Contact Person's Information:

a. Salutation:Dr.Hon.Mr.Ms.RabbiRev.Other
b. First name:     c. Mi:      d. Last Name:

e. Title/Position:

5. Organization Contact Information:

a. Physical Address:

b. Postal Address:

c. City: d. State: Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Dist. of Col. Fed. State Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota North Mariana Is. Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming e. Zip Code:

f. Phone:

Office:
Cell:      Fax:

g. Email:

h. Website:

i. County: Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren

6. Targeted Population Demographic

a. Targeted Group(s):

Black/African American
American Indian or Alaska Native
Asian

Hispanic/Latino

Native Hawaiian or Pacific Islander
Non-Minority
Other, please specify: