Skip to content
New Member Application
Organizational Info
Membership dues are based on an organization's total (from all sources) annual substance abuse service budget.
Membership begins at the time of first payment and is renewable after 12 months
Payment options are available: Annual, Semi-Annual, Quarterly, Monthly. Your payment is calculated by dividing the annual dues amount by the appropriate number of payments and round the figure to the lowest whole dollar amount.
*
1.
Organization Information
(Required.)
Voting Representative
*
Company
*
Address
*
Address 2
City/Town
*
State/Province
*
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
*
Country
Email Address
*
Phone Number
*
2.
Please list any additional staff member who you would like us to include in our member distribution list
Name
Email Address
*
3.
Please indicate who at your organization should receive invoices related to ASAP dues payments.
(Required.)
Name
Email Address
4.
Is there another name (alias or DBA) that your payments will be coming from?
