Registration- In Person (non-student) – Northern New England Society of Addiction Medicine

Name *

First

Last

Credentials *

Physician
Physician Assistant
Nurse Practitioner
Nurse (All Other)
Social Worker (LSW)
Social Worker (LCSW)
Social Worker (All Other)
Certified Counselor
Pharmacist
Other (community member, administrator, journalist, etc. – please specify below)

Additional details

Email *

Are you an ASAM member? *

NOTE: ASAM members qualify for member discounted registration fee.

Are you a NNESAM member? *

NOTE: ASAM/NNESAM members qualify for member discounted registration fee.

City and State of Primary Professional Location *

First

Last

Please list any food allergies (or indicate "none") *