Provider Membership Renewal Application



Welcome to the Ohio Provider Resource Association!
Thank you for renewing your OPRA Membership. Take full advantage of all the great benefits OPRA has to offer!

Reminders and Details:
	Ohio Provider Resource Association engages in lobbying, and under federal law, 10% of membership dues are not deductible as a business expense.
	OPRA’s Membership Year is from January 1 through December 31.
	The dues structure described herein is applicable solely to the 2020 Membership Year. Revisions may affect the dues structure for following years.
	Upon completion of this form, an invoice will be emailed to you within 1-2 business days. If you have any questions regarding your OPRA Membership, please feel free to contact us at (614) 224-6772.

Organization Information
Type
Organization Name
Website
Main Phone

Physical Address
	CHECK if Billing address and Physical address are the SAME
Address

City
State
Zip

Billing Address
Please provide Billing Address ONLY if different from above.

	CHECK if Billing address is DIFFERENT from Physical address
Address

City
State
Zip

Your Contact Information
First Name
Last Name
Title
Email

Organization's CEO, Executive Director or Owner (if different from above)
First Name
Last Name
Title
Email

Billing Contact (if different from above)
First
Last
Title
Email


Additional Organization Information
Please list all other names by which your organization is known and/or subsidiary entities which your organization owns that fall under this membership:


Total # Employees, including in all locations:


Please select all applicable services your organization provides: (use SHIFT, CONTROL or COMMAND to multi-select)


Approximately how many individuals do you serve a year?


Please choose the following counties you provide services in:
	All 88 Counties	Adams	Allen
	Ashland	Ashtabula	Athens
	Auglaize	Belmont	Brown
	Butler	Carroll	Champaign
	Clark	Clermont	Clinton
	Columbiana	Coshocton	Crawford
	Cuyahoga	Darke	Defiance
	Delaware	Erie	Fairfield
	Fayette	Franklin	Fulton
	Gallia	Geauga	Greene
	Guernsey	Hamilton	Hancock
	Hardin	Harrison	Henry
	Highland	Hocking	Holmes
	Huron	Jackson	Jefferson
	Knox	Lake	Lawerence
	Licking	Logan	Lorain
	Lucas	Madison	Mahoning
	Marion	Medina	Meigs
	Mercer	Miami	Monroe
	Montgomery	Morgan	Morrow
	Muskingum	Noble	Ottawa
	Paulding	Perry	Pickaway
	Pike	Portage	Preble
	Putnam	Richland	Ross
	Sandusky	Scioto	Seneca
	Shelby	Stark	Summit
	Trumbull	Tuscarawas	Union
	Van Wert	Vinton	Warren
	Washington	Wayne	Williams
	Wood	Wyandot

Membership Dues
The dues structure described herein is applicable solely to the 2020 Introductory Membership Year. Revisions may affect the dues structure for following years.

Please record your organization's EGR for the next calendar year below.

In figuring your Estimated Gross Revenue, do NOT include revenue from fundraisers, United Way, gifts and donations. If your organization provides services to non-DD populations, you only need to include the revenue related to individuals with I/DD.

You may select one of the following payment plans for your dues payments.
You will be sent an invoice based on your payment choice below
	Annual
	Your annual dues payment is due on or before March 15th.
	Semi-Annual
	Your 1st semi-annual dues payment is due on or before March 15th. Your 2nd semi-annual dues amount will be invoiced by the end of June. A 5% discount is applied to the 2nd half dues amount if this payment plan is selected and the 1st payment is received by March 15.
	Quarterly
	Your 1st quarterly dues payment us due on or before March 15th. Successive quarterly dues amounts will be invoiced by the end of each following quarter.

A LOOK AHEAD
OPRA offers a special introductory rate for first year members. Second year OPRA members receive a 50% discount on the standard dues rate for OPRA membership. Third year and beyond, OPRA members pay the full standard dues rate for OPRA Membership. We encourage new OPRA members to talk with other members about the value of OPRA membership and how you can get the best return on your dues investment.