National Alliance of Methadone Advocates Inc
435 Second Avenue
New York, NY 10010

Membership Application

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

Organization: __________________________________________________________________________

Title: _____________________________________________ Degree(s): ________________________

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 _____

$_______	Individual Membership Dues: $25 a year USA $40 a year International 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: __________________________________________________________
$_______	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 of Methadone Advocates is a not-for-profit organization.
$_______	Total Enclosed

Please direct all membership inquiries to:
Carolyn Miranda, CMA Membership Director

Office Use Only

DOM: _________ Amount: ________
Date: __________ Authorized: ______

Notes	101B-R032003
1. In the past NAMA has accepted memberships without payment of dues, however such memberships are not entitled to mailings. A partial dues payment of $10 will avoid this happening to you should you not be able to afford the full amount of $25.

Last Modified: September 6, 2008