Note: This registration form is for those individuals who have been selected by their state leadership (governor, house speaker, or senate president) to serve on a State Team to attend the Addiction Studies Program for the States workshop. If you are not a member of a State Team and wish to attend a workshop, please contact your governor, house speaker, or senate president. If you have been selected to serve on a team, please print, fill out, and mail or fax to address below.

Expenses for air fare, lodging, and meals are covered by the Addiction Studies Program for the States. You will be reimbursed for travel expenses after the workshop.

Which workshop is your State Team scheduled to attend?

2007

____ Thursday-Saturday, September 6-8
Addiction Studies Workshop for the States
Chicago, Illinois

____ Thursday-Saturday, October 25-27
Addiction Studies Workshop for the States
San Antonio, Texas

2008

____ Thursday-Saturday, May 1-3
Addiction Studies Workshop for the States
Location to be Determined

____ Thursday-Saturday, September 18-20
Addiction Studies Workshop for the States
Location to be Determined

Application Form

Name
_________________________________________________________________________________________
Title
_________________________________________________________________________________________
Branch of Government
_________________________________________________________________________________________
Address
_________________________________________________________________________________________
City
_________________________________________________________________________________________
State
_________________________________________________________________________________________
Zip
_________________________________________________________________________________________
Phone (Office)
_________________________________________________________________________________________
Fax
_________________________________________________________________________________________
Phone (Home)
_________________________________________________________________________________________
Phone (Cell)
_________________________________________________________________________________________
Pager
_________________________________________________________________________________________
Email
_________________________________________________________________________________________
Dietary restrictions, if any
_________________________________________________________________________________________

Please fax to:

Allison C. Colker, J.D., Esq.
Addiction Studies Program for the States
National Conference of State Legislatures
444 North Capitol Street N.W., Suite 515
Washington, D.C. 20001
Fax Number: 202-737-1069

Confirmation of registration will be received within 1 week after registration deadline. Attendees who register and later cancel will be billed for the cost of holding their room. Your airline ticket will not be reimbursed. Diane Joyner, Administrative Assistant for the program, will handle logistics for you. Her number is 336-713-7161.

For more information call 202-624-3581.