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National Alliance of Methadone Advocates Inc.                                                                                                    
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NAMA
Membership Office
435 Second Avenue
New York, NY 11000

Membership
Application

Name:   _______________________________________________________ 

Organization:  ________________________________________________________________________

Title:  ________________________________________________________ Degree(s):__________________________

Address:  ________________________________________________________________________

Address:  ________________________________________________________________________

City:   _____________________________________   
State:   ______Postal Code:   ________Country:  
___
Home Phone: (___)__________________________   Work
Phone:   (___)______________________   
Alternate Phone:(___)________________________Fax:   (___)______________________________ 

     Email:______________________________________

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 USA                $40
a year International
        Includes all the rights and
privileges, a subscription to The Ombudsman and bulletin alert mailings. 

Note:  No one will be denied membership if they do not have money,
however in the event that our resources are low these members may not receive
The Ombudsman, bulletin alerts or other mailings. A partial dues payment of
$5 will avoid this happening to you should you not be able to afford the full
amount of $15.
$_______        Family Membership       
Dues:  $10 a year for UD and International. 
Additional family members many join at a reduced cost which includes all
the rights and privileges of Individual Membership, except that only theperson
paying the full membership shall receive mailings..
        Name:  __________________________________________________________________

        Please enter the names for
additional Family Memberships on the back.
$_______        Institutional Membership    
Dues:  $100 a year USA                $115
a year International
Institutional Membership is for institutions and NOT individuals. A Contact
Person designated by the institution. Institutional Membership includes all
the rights and privileges of Individual Membership which shall be carried out
by the Contact Person.. In addition to a subscription to The
Ombudsman and bulletin alerts Institutional Members shall receive new
Education Series.
Contact Person:  __________________________________________________________

$_______        Wont you please include
a donations of $15 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                                                  

                No
one is ever denied membership because they dont have the money.     

Please direct all membership inquiries to Howard Lotsoff.

 Howard
Lotsoff ,
Membership Director
[email protected]

 
Office Use Only

Authorized
By_____DOM________

 
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