Individual Membership Application

Please complete the application below to complete the application process. Feel free to call the AATOD office at 212-566-5555 extension 105 or email us at if you need assistance.

First Name (required)

Last Name (required)

Degree(s) (required)


Position/Title (required)

Street Address (required)

City (required)

State (required)

Zip (required)

Phone (required)

Email Address (required)

Professional Interests: (Please check all that Apply)

eSignature (required)
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