2023 OPRA Sponsored Provider Membership Application



Welcome to the Ohio Provider Resource Association!
We hope you enjoy being an OPRA Member. Please take full advantage of all the great benefits OPRA has to offer!

Reminders and Details:
	OPRA’s Membership Year is from January 1 through December 31.
	Please complete the following information as 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.

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

Name of County Board Sponsoring Your OPRA Membership
County Board Name


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

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.