2022 OPRA Public Entity 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 as accurately as possible to help us better serve you - Thank you!

Organization Information
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 Superintendent (if different from above)
First Name
Last Name
Title
Email

Billing Contact (This individual will receive all invoices from OPRA)
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:


If your Board still provides services, please list them here:


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
Public Entity Membership is designed specifically for Ohio's local county boards of developmental disabilities and regional Council of Governments (COG).

$1,000 - Public Entity Level 1
	This member will have access to Friday Calls, Weekly Friday 5 and other information that is not for members only. This member will also have access to monthly “partnership” meeting with the OPRA Team and members.
$3,000 - Public Entity Level 2
	In addition to Public Entity Level 1 member benefits this member will have access to the HR, Health, Day Array, Employment, ICF and Residential Waiver Committees (The chairs of the committees have the opportunity to declare any meeting as a “provider only” meeting if there is information being discussed that is crucial to OPRA policy decisions and/or strategies).
Small Provider Support Project - $1,000 per provider
	A public entity or another group may have the opportunity to sponsor/pay for a 1-year OPRA membership for a small provider (small provider = gross revenue less than $500,000). The small provider would have full access to the full benefits provided by OPRA to its Provider members.
	A public entity that sponsors either 2 or 3 small providers will receive a complimentary Public Entity Level 1 Membership. A Public Entity that sponsors 4 or more small providers will reiceve a complimentary Public Entity Level 2 membership. For every 4 small providers sponsored, the public entity will receive an additional small provider OPRA membership free of charge.

Please choose the level appropriate to your profile.
You will be sent an invoice based on your payment choice below

Membership Level
	* If selecting Small Provider Support Program, please contact OPRA to learn how to add your Small Providers to the OPRA Membership Roster.


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	?