National Alliance for Medication Assisted Recovery 435 Second Avenue New York, NY 10010      

Membership Application

Name:   _______________________________________________________   Mr. ___  Ms. ___  Dr. ___

Organization:  __________________________________________________________________________

Title:  _____________________________________________  Degree(s):  ________________________

Address:  _____________________________________________________________________________

Address:  _____________________________________________________________________________

City:   __________________________________   State:   ____________   Postal Code:   _____________

Email:  ______________________________________  Country:   ________________________________

Home Phone: (____)___________________________   Work Phone:  (____)_______________________

Alternate Phone:  (____)________________________   Fax:  (____)______________________________

If you have email may we send you bulletin alerts electronically. (This will get bulletin alerts to you quicker than usual mail)  

Yes  _____   No _____

Types of Membership

$_______

Individual Membership   Dues: $25 a year

Includes all the rights and privileges, a subscription to the newsletter and bulletin alert mailings.1

$_______

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:  __________________________________________________________

$_______

Wont 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.

$_______

Total Enclosed

Office Use Only

DOM: _________  Amount: ________

Date: __________  Authorized: ______

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