Associate Membership Application

Welcome to the Ohio Provider Resource Association!

Reminders and Details:
 OPRA’s Membership Year is from January 1 through December 31.
 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.

Company Information

Type
Company 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 Company Information

Please list all other names by which your company is known and/or subsidiary entities which your company owns that fall under this membership:
 
Please list all applicable services your company provides:
 
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

Associate Membership is for businesses and organizations that support Providers. OPRA also offers a level of Associate Membership for friends and relatives of individuals with DD. Please choose the level appropriate to your profile.
Please select the dues payment that applies to your organization
You will be sent an invoice based on your payment choice below.
$500 - Businesses and organizations that support providers but do NOT provide direct residential or other community-based DD support services.
$35 - Parent/Relative of an individual with DD.
   - denotes required fields