Association Name:

Contact information for the association president, executive director, or other:

Name:

Position with the Association:

Address:

City: State: Zip:

Phone:

Fax:

Email:

Web Site:

Is the association membership primarily comprised of AOD treatment/prevention agencies? Yes No

If no, is the association an integrated MH/AOD association? Yes No

Approximately how many members?

Does the association have staff? Yes No

Primary activities of the association: