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Membership Application


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ATTN: M.D.’s and D.O.’s - Join Now at ½ the regular rate. Your membership will be valid through 12/31/2010. Rates listed are ½ of the regular rates for Regular Members and Early Career Physician Members. This promotional offer is good for a limited time, so sign up today. The offer is only available on new ASAM memberships.
 
Personal Information:
Org:
Name:
Dr.         
First Name: * Last Name: *
Designation:
EMail: *
Work Phone:
Home Phone:
Fax:
Chapter:
 
Main Address:
Address: *
Address Line 2:
City:
St/Prov:**
Zip:**
Country:**
 
Home:
Address:
Address Line 2:
City:
St/Prov:**
Zip:
Country:
 
Areas of Expertise:
Primary Specialty
Board Certified?
Secondary Specialty
Board Certified?
Medical School: *
Medical School Graduation Year: * (yyyy)
Residency School: *
Length of Residency: *
Year Completed: *  (yyyy)
Residency Specialty:
Medical License Number: *
State of Medical License: *
Are you an AMA member?
If you are not, click here to join the AMA
State Medical Association?
County Medical Association?
Communication Preferences:
Your contact information will be INCLUDED in:
   Approved Mailing List Rentals
 On-line Membership Directory
Professional Interests:
(please check up to two areas of interest)
   Addiction Medicine
 Addiction Medicine in the Criminal Justice System
 Child & Adolescent Addictions
 Cross-Cultural Clinical Concerns
 Developing Residencies and Fellowships
 Dual Diagnosis
 Family and Generational Issues
 Forensic Medicine
 Forensic Science - Expert Witness
 Geriatric Alcohol & Substance Abuse
 Infectious Disease
 Legislative Advocacy
 Medical Review Officer
 Nicotine Dependence
 Opioid Agonist Treatment
 Pain & Addiction
 Pharmacological Issues
 Policy Development Guidelines
 Practice Guidelines
 Public Policy
 Screening and Brief Intervention
 Therapeutic Communities
 Treatment Criteria, Outcome and Clin Performance Measure
Membership:
Member Type: *
If you are a student enrolled and in good standing in a formally accredited allopathic or osteopathic medical school, please submit the pdf version of the application along with your certifying letter from your school or call the ASAM office at (301) 656-3920 for an application.
If you have a promotional code, enter it here:
 
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