Please select one: New Member Renewing/Changing Membership

Please select desired membership level:

Full Member $200
Qualifications: Full-time employment as director of an alternative program
Privileges: Full privileges including voting

Associate Member $150
Qualifications: Any alternative staff, peer assistance advocate, regulatory board disciplinary staff, treatment professional, or other interested person.
Privileges: Full privileges excluding voting.
   I qualify for reduced dues of $50 (please check reason below)
      I am a Volunteer Peer Assistance Advocate
      I am a Full time Student

Organizational Member $400
Qualifications: Any supporting organization. Includes three transferable individual memberships (If applicable one Full and two Associate, otherwise, three Associate memberships)
Privileges: Full privileges for three members as qualified

Please fill out the following:

Organization:

Address:

Phone: Fax:

Email:

Member Name(s) Please list one name if individual membership, up to three if organizational:

1. NAME (Last, First) : TITLE:

EMAIL AND PHONE (IF DIFFERENT THAN ABOVE):

2. NAME (Last, First) : TITLE:

EMAIL AND PHONE (IF DIFFERENT THAN ABOVE):

3. NAME (Last, First) : TITLE:

EMAIL AND PHONE (IF DIFFERENT THAN ABOVE):

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