Membership Application
Please complete and send to: National Alliance of Methadone Advocates
435 Second Avenue
New York, NY, 10010
Name: Mr / Ms _______________________________________________________________________
Organization: _____________________________________ Title: ______________________________
Address: ____________________________________________________________________________
City: ___________________________________________________ State: ______________________
Zip Code (Postal Code): ____________________ Country: ____________________________________
Telephone: ______________________________________ Circle One: Day Eve
Telephone: ______________________________________ Circle One: Day Eve
Fax: ________________________________ E-Mail: _______________________________________________________
TYPE OF MEMBERSHIP
__________ Individual Membership Dues: $10/Year USA $25/Year International
Includes all the rights and privileges of membership and a one year
subscription to The Ombudsman.
__________ Family Membership Dues: $5/Year each $10/Year International
Additional family members may join at a reduced cost which includes
all the rights and privileges of Individual Membership, except only one
subscription to the newsletter will be entered in the name of the person
paying full membership.
Name(s): _________________________________________________________
__________ Institutional Membership Dues: $50/Year USA/International
Includes all the rights and privileges and a one year subscription to
The Ombudsman.
Contact Person: __________________________________________________________
__________ Won't you please include a donation of $10 or more to help offset the cost of
membership for those unable to pay?
____________ Total Enclosed
Please make checks payable to the National Alliance of Methadone Advocates, Inc.
The National Alliance of Methadone Advocates is a not-for-profit organization
registered in the State of New York.
