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Please Mail Registration Form To:
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SUFFOLK COALITION PADD
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471 Townline Road
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Suite 101
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Hauppauge, NY 11788
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SUFFOLK COUNTY ADDICTION TRAINING (SCAT)
As of
02/05/12
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Check Box
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Date
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Training
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Member Fee
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Non-Member Fee
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Fee
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Membership Fee ($50) __________
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Total Enclosed __________
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METHOD OF PAYMENT
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Please enclose your personal check or money order, payable to: SUFFOLK COALITION PADD. If credit card payment, please provide information as indicated below:
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 VISA
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MasterCard
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Acct. No.
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__________________________________
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_______________
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Signature
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Exp. Date
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NAME: __________________________________________________________________
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AGENCY/SCHOOL AFFILIATION: _________________________________________
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MAILING ADDRESS: (Please Circle One) Home Agency/School
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STREET: _________________________________________________________________
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CITY, STATE, ZIP CODE: ___________________________________________________
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PHONE: (WORK) _______________________ (HOME) _______________________
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E-MAIL: _________________________________________________________________
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