2022 OPRA Associate Membership Application

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 2022 Membership Year. Revisions may affect the dues structure for following years.
 Please complete the following information accurately as possible to help us better serve you - Thank you!
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 select the dues payment that applies to your organization
You will be sent an invoice within 1-2 business days based on your member choice below.
Your dues payment is due upon receipt of your invoice
$500 - Associate MembersThis member will have access to Friday Calls, Weekly Friday 5 and other info that is not for members only. This member will also have access to a monthly "partnership" meeting with the OPRA Team and members.
$35 - Friend/Relative of a person with I/DDThis member will have access to Friday Calls, the Weekly Friday 5 and other info that is not for members only.
Membership

Terms and Conditions

By signing the form below, the Organizational Representative understands that an OPRA Staff member may confirm subscriptions and inquire about any additional employee subscriptions. The Organizational Representative also consents to the organization’s listing as an OPRA Member on any/all published materials.
I certify that the information on this form is current, accurate, and complete.
Signature
Date ?
   - denotes required fields