ASSOCIATION MEMBERSHIP APPLICATION

CONFIDENTIAL

BUSINESS NAME: ____________________________________________________________

ADDRESS: ________________________________________________________________

(CITY)_________________________(STATE)__________________(ZIPCODE)_____________

MAILINGADDRESS:_________________________________________________________________________________________________________________________________________

PHONE NUMBER: ( ) _______________ FAX #: ( ) ________________________

E-MAIL ADDRESS ________________________ WEBSITE: _________________________

IS YOUR ORGANIZATION: FOR-PROFIT ___ NOT FOR PROFIT ___

NAME OF CEO/EXECUTIVE: _____________________________________________________

REPRESENTATIVE (IF OTHER THAN CEO) ________________________________________

TITLE: _______________________________________________________________________

PROFILE OF YOUR ORGANIZATION: ____________________________________________

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SERVICES PROVIDED: (list all that apply)

___ TREATMENT: __________________________________________________________

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___ PREVENTION: __________________________________________________________

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___ OTHER: ___________________________________________________________

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WHY ARE YOU SEEKING MEMBERSHIP? _________________________________________

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MEMBERSHIP DUES: (Check one)

____ DUES ARE BASED ON THE ALCOHOL AND DRUG BUDGETS OF YOUR ORGANIZATION. THE AMOUNT OF DUES OWED IS DETERMINED BY PLACING YOUR TOTAL BUDGET AMOUNT WITHIN THE RANGE. THE MINIMUM DUES ASSESSMENT IS $350 AND THE MAXIMUM IS $10,000. A $10,000 MEMBERSHIP ENTITLES THE ORGANIZATION TO A BOARD OF DIRECTOR'S SEAT, ALL OTHER

BOARD SEATS ARE ELECTED. THE CAADSP FISCAL YEAR BEGINS JULY 1.

PLEASE LIST YOUR ALCOHOL AND DRUG BUDGET. $ .

The Range = 0 $ 50,000 $ 350.

50,001 - 100,000 $ 700.

100,001 - 150,000 $1,050.

150,001 - 200,000 $1,400.

200,001 - 250,000 $1,750.

250,001 - 300,000 $2,100.

300,001 - 350,000 $2,450.

350,001 - 400,000 $2,800.

400,001 - 450,000 $3,150.

450,001 - 500,000 $3,500.

500,001 - 550,000 $3,850.

550,001 - 600,000 $4,200.

600,001 - 650,000 $4,550.

650,001 - 700,000 $4,900.

OVER $5,000.

BOARD SEAT $10,000.

____ ASSOCIATE MEMBERSHIP IS AVAILABLE @ $240 PER YEAR.

(NON-VOTING, NON AOD AGENCY)

____ FRIEND OF THE ASSOCIATION IS AVAILABLE @ $120 PER YEAR.

(INDIVIDUAL, NON VOTING - NON AOD AGENCY)

I hereby make application for membership in the Colorado Association of Alcohol and Drug Service Providers, and if accepted, will abide by its by-laws, support its objectives and pay the established dues.

AUTHORIZED SIGNATURE: __________________________________________________

TITLE: __________________________________________________

ORGANIZATION: __________________________________________________

DATED: _______________________

FOR CAADSP USE ONLY:

APPROVED: __________ EFF. DATE: _____________ ANNUAL DUES AMOUNT: $_______