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National Alliance for Medication Assisted Recovery
435 Second Avenue
New York, NY 10010
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Membership Application
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Name: _______________________________________________________ Mr. ___ Ms. ___ Dr. ___
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Organization: __________________________________________________________________________
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Title: _____________________________________________ Degree(s): ________________________
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Address: _____________________________________________________________________________
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Address: _____________________________________________________________________________
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City: __________________________________ State: ____________ Postal Code: _____________
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Email: ______________________________________ Country: ________________________________
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Home Phone: (____)___________________________ Work Phone: (____)_______________________
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Alternate Phone: (____)________________________ Fax: (____)______________________________
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If you have email may we send you bulletin alerts electronically. (This will get bulletin alerts to you quicker than usual mail)
Yes _____ No _____
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Types of Membership
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$_______
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Individual Membership Dues: $25 a year
Includes all the rights and privileges, a subscription to the newsletter and bulletin alert mailings.1
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$_______
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Institutional Membership Dues: $110 a year USA/International
Institutional Membership is for institutions and NOT individuals. A Contact Person is designated by the institution. Institutional Membership includes all the rights and privileges of Individual Membership which shall be carried out by the Contact Person. Institutional Members will receive a Certificate of Membership for their respective institution, organization or program.
Contact Person: __________________________________________________________
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$_______
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Won’t you please include a donation of $25 or more to help offset the cost of those who cannot afford membership.
The National Alliance for Medication Assisted Recovery is a not-for-profit organization.
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$_______
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Total Enclosed
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Office Use Only
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DOM: _________ Amount: ________
Date: __________ Authorized: ______
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