Minority Organization and Stakeholders' Contact List

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 (required field) 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: Org Name

2. Organization Type:

3. Type of Services:

4. Contact Person's Information:
a. Salutation:
b. First name: required     c. Mi:      d. Last Name: required

e. Title/Position:

5. Organization Contact Information:
a. Physical Address: required

b. Postal Address:

c. City: required d. State: e. Zip Code: required

f. Phone:
Office: Phone Number
Cell:      Fax:

g. Email: Email

h. Website:

i. County:

6. Targeted Population Demographic
a. Targeted Group(s):