2025 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 2025 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

Your dues payment is due upon receipt of your invoice

$500 - Associate Members	This member will have access to Friday Calls, Weekly Friday 5 and other info that is not for members only.
$75 - Friend/Relative of a person with I/DD	This member cannot be employed by a provider agency. You 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	?