SJTSA
Serving Atlantic, Cape May, Cumberland,
and Salem Counties

            Established 1998                                      

                              NJ DIVISION OF HIGHWAY TRAFFIC SAFETY
                              SOUTH JERSEY TRAFFIC SAFETY ALLIANCE

                 Saved By The Seat Belt Program

Have you, or someone you know, ever been saved from serious injury or death by a seat belt or air bag while in an automobile? Or do you know a child that escaped death or serious injury while traveling in a federally approved child safety seat? If so, we would like to hear about it. Those that are considered to be eligible for the program will be contacted and asked to join the program.

By joining the SAVED BY THE SEAT BELT program, you can help save the lives of others. With your permission, we will acknowledge and publicize your lifesaving experience throughout South Jersey in an effort to encourage other to use seat belts and child passenger seats. You will be invited to attend press conferences, award ceremonies and other activities and given a baseball cap with the program name and official certificate

The Saved By The Seat Belt Program was created by the NJ Division of Highway Traffic Safety and is being instituted in Atlantic, Cape May, Cumberland and Salem Counties by the South Jersey Traffic Safety Alliance.

 MEMBERSHIP APPLICATION/NOMINATION FORM

Send the requested information below to SJTSA at 1173 E. Landis Ave, Vineland, NJ  08360 or fax to 856-794-2549.

Your Name, Address, Telephone No.

If you are using this form to nominate someone, that person's
name, address and phone number

Accident Description:
Date:
Town were occured:
Street Location:
Detailed description:

Vehicle Information:
Vehicle Tyep:    Car___   Truck___   Van___    Bus___
Make and Model:
Extent of damage to vehicle:
Number of people in vehicle:
Type of restraint used:
    ___Lap Belt/Shoulder Belt         ___Air Bag Only
    ___Lap Belt Only                      ___Air Bag/Seat Belt
    ___Shoulder Belt Only              ___Approved Child Restraint

Briefly describe any injuries:

Other Vehicles:
Was another involved?
Extent of damage?
How many occupants?
Any injuries:

 If you received a copy of police report please attach a copy.

Questions contact the SJTSA at 856-794-1941.  

1173 E. Landis Avenue, Vineland, NJ 08360   Tel: 856-794-1941  Fax: 856-794-2549