Please complete this Registration Form, and mail it along with your money order to: ACNY, 2 Washington Street, 7th Floor; NY, NY 10004
* Denotes required information.
First Name *	Last Name *	Date *
Home Address 1 *	Home Address 2
City *	State / Province * Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Colorado Connecticut Caribbean Military Address Delaware District of Columbia European APO/FPO Far East APO/FPO Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ontario Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Quebec Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming	Zip / Postal Code *
Home Phone * (  )  -	Home Fax (  )  -
Affiliation *	Job Title *
Business Address 1 *	Business Address 2
City *	State / Province * Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Colorado Connecticut Caribbean Military Address Delaware District of Columbia European APO/FPO Far East APO/FPO Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ontario Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Quebec Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming	Zip / Postal Code *
Business Phone * (  )  -	Business Fax (  )  -
E-mail Address *
I am interested in * (select one) CASAC Credentialing Recredentialing Full-Time Program Part-Time Program	Previous training in alcohol/substance abuse * (select one) Yes No	Currently practicing in the alcohol/substance abuse field * (select one) Yes No
School / College Degree Awarded Dates *
Course *