Membership Information You have selected the Harm Reduction Partner membership level. The price for membership is $100.00 now and then $100.00 per Year. Account Information Username Password Show Password Confirm Password Email Address Confirm Email Address Full Name LEAVE THIS BLANK Already have an account? Log in here Organization The organization is the holder of the Partner Membership. Organization Name Address 1 Address 2 City State Zip Organization Contact Contact First Name Contact Last Name Email Address Number Type Office Phone Cell Phone Other Phone Phone Number Before you go How did you hear about the ASAP Alliance? NH Behavioral Health Summit Other Event Word of Mouth Google Other Would you allow ASAP Alliance to list your organization as a member? Yes No Terms of Agreement By checking this box, I certify that I am authorized to enroll this organization in the membership program and agree to these terms on its behalf. I acknowledge that all materials, resources, and information are provided in good faith and for general informational purposes only. While every effort is made to ensure accuracy, the organization providing this membership makes no representations or warranties, express or implied, regarding the completeness or reliability of the information and shall not be held liable for any errors, omissions, or any results arising from its use. I agree to the Terms of Agreement Group Account Information This purchase includes 10 additional seats. Group members will be able to claim the Member Partner membership level. Pay by Check Please make checks payable to: ASAP Alliance of NH Checks should be mailed to: ASAP Alliance of NH 1 Pillsbury Street, Suite 200 Concord, NH 03301 Processing...
