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:  __________________________________________________________
$_______ 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.
$_______ Total Enclosed



Office Use Only
DOM: _________  Amount: ________
Date: __________  Authorized: ______


  101B-R032003
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Copyright
Last Modified: July 18, 2009
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Recovery