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
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$_______ |
Individual Membership Dues: $25 a year Includes all the rights and privileges, a subscription to the newsletter and bulletin alert mailings.1 |
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$_______ |
Institutional Membership Dues: $110 a year USA/International Institutional Membership is for institutions and NOT individuals. A Contact Person is designated by the institution. Institutional Membership includes all the rights and privileges of Individual Membership which shall be carried out by the Contact Person. Institutional Members will receive a Certificate of Membership for their respective institution, organization or program. Contact Person: __________________________________________________________ |
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$_______ |
Wont you please include a donation of $25 or more to help offset the cost of those who cannot afford membership. The National Alliance for Medication Assisted Recovery is a not-for-profit organization. |
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$_______ |
Total Enclosed |
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