2023 OPRA New Provider Membership Application

Welcome to the Ohio Provider Resource Association!

We hope you enjoy your introductory membership rate and 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 an introductory rate applicable solely to new members in the 2023 Membership Year. Introductory membership dues are structured to increase in year two as outlined under the Join tab on the OPRA website. 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!

• 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 subsidiary entities which your organization owns that fall under this membership:
 
Total # Employees, in all locations:
 
Approximately, how many individuals do you serve a year?
 
Please select all applicable services your organization provides: (use SHIFT, CONTROL or COMMAND to multi-select)
 
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

Introductory Membership Dues

New OPRA Provider Members will receive a one-time introductory dues discount of 35%. First year membership dues are structured to increase in year two. Revisions may affect the dues structure for following years.
Please record your organization's EGR for 2023.
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.
EGR
Please choose your membership dues level based on your EGR:
Membership
Please select one of the following payment plans for your dues payments.
Payment Plan
An invoice will be emailed within 1 to 2 business days based on your membership dues level
Your dues payment is due upon receipt of your invoice

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 ?

A LOOK AHEAD

OPRA offers a special 35% discount as an introductory rate for first year members. Second year OPRA members and beyond 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.

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