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REGISTRATION FEE PAYMENT INFORMATION.

By completing this form, you certify that:

1) You or at least one member of your staff has completed the SMART Recovery Online Facilitator or Onsite Training.

2) You/your organization provides an addictive behavior program track that is broadly based on the scientific findings of which SMART Recovery is also based.

3) You/your organization desires to provide an educational component for your patients/clients, and prepare them for SMART Recovery meetings. 

4) Any SMART Recovery publications distributed to your clients will be purchased from SMART Recovery.

5) You/your organization grants permission to publish your name/organization on the list of treatment programs registered with SMART Recovery.

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1. Submitted by Name:

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2. Your Phone Number:

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3. Your Email Address:

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4. Name of Staff Member who completed the SMART Recovery Get SMART FAST Online Facilitator Training or Onsite Training Program:

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5. Date Get SMART Fast Online Training Session or Onsite Training Session was completed:

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6. Organization's Name:

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7. Street Address:

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8. City:

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9. State:

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10. Zip/Postal Code:

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11. Country:

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12. Phone number to be listed on the SMART Recovery website:

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13. Website Address:

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14. I/My organization is (check one):

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15. My organization is (check one):

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