CPAO MEMBER APPLICATION
Enriching the lives of people with disabilities
Which Type of Membership Are You Requesting?
Provider
Associate
Professional
Agency:
Contact:
Email
example@example.com
Phone Number
Fax Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Types of Services Provided (Check All That Apply):
A & D Services
I/DD Services
Case Management/Brokerage
Mental Health Services
Residential Services
Children Services
Senior Services
Counselling Services
Training/Technical Support Services
Employment/DSA Services
Other
Number of Individuals Supported:
Number of DSPs Represented:
Total Number of Employees:
Number of Physical Locations/Sites:
Location(s) of Services Provided:
How Did You First Become Aware of CPAO?
What Benefits Would You Like To Get Out Of Your Membership?
How Would You Like To Contribute To CPAO Through Your Membership?
Signature
Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
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