New Member Application

Criteria for Membership:

Eligibility for membership requires that the candidate holds a position of authority in Quality Assurance, Quality Control or Regulatory Compliance in the pharmaceutical or related industries.

Each application must be reviewed by the NJPQCA Membership Committee. Please complete the following information and mail to:

Dr. Sigita Zibas
NJPQCA
PO Box 740
Kenilworth, NJ 07033
Phone: (908) 673-9683
Fax: (908) 673- 2770
Email: szibas@celgene.com

The Membership Committee will contact each applicant after the application has been reviewed.

Name:

First:

MI:

Last:

Title:

Duties and
Responsibilities:

Company Business:

Pharmaceutical Manufacturing
Other (please specify)

Company:

Department/
Division/
Responsibility

Dept:

Title of Direct Supervisor:

Number of Managers/Supervisors reporting to you:

Total Number of Individuals reporting to you:

Number of years of experience in Quality or regulatory affairs:

Company Address:




City:	State:	Zip:

Home Address:




City:	State:	Zip:

Phone:

Fax:

Email:

Other Professional
Society Affiliations

Professional Reference:

Name/Title/Company/Phone:

Questions/Comments?