NEW Provider Membership Application
To submit your your Provider membership application please complete all questions. NOTE: Membership is for valid the calendar year (January through December) and must be renewed annually.
Organization Name
*
Organization Main Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Organization Phone Number
Organization Website
*
Would you like a link to your website posted on ours (www.providers.org)?
Yes
No
Number of FULL TIME Employees:
# of FTE's
Number of PART TIME Employees:
# of PTE's
Number of VOLUNTEERS:
# of volunteers
Number of INTERNS:
# of interns
Funding Sources. Check all that apply.
DCF
DDS
DMH
DPH
DTA
DVS
DYS
EEC
MCH
MCDHH
MRC
ORI
OOM
DHCD
DOEA
Other
What state agency is the Primary Purchasing Agency?
*
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Opportunities to be engaged with the Council. Check all that apply.
Link your business/organization website on our webpage
Interest in presenting a webinar/training for our members in 2025
Advertise in newspaper, e-newsletters in 2025
Share the Councils' digital badge on your website
In person or virtual member visit from the Providers' Council
Delta Dental/insurance products
Fleet management solutions
Furniture needs
Unemployment tax management assistance
Organization Contact Information
Include contact information for any of the following staff members.
Membership Contact Person:
*
First Name
Last Name
Title
*
Email
*
example@example.com
Executive Leader:
Same as Membership Contact
President/CEO/Executive Director:
Executive Assistant:
Same as Membership Contact
Executive Assistant:
Financial Leader:
Same as Membership Contact
CFO/Financial Leader:
HR Director:
Same as Membership Contact
HR Director:
Communications Director:
Same as Membership Contact
Communications Director:
Public Policy Director:
Same as Membership Contact
Public Policy Director:
Learning/Training Director:
Same as Membership Contact
Learning/Training Director:
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Annual Revenue and Dues Calculations
Annual Revenue (line 12 of your most recent 990).
*
Attach a copy of the first page of your most recent 990.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Dues Category Selection (dues are based on line 12 of your most recent 990)
*
Under $1M = $525
$1M - $2M = $1,050
$2M - $4M = $2,775
$4M - $6M = $3,950
$6M - $8M = $5,000
$8M - $10M = $5,300
$10M - $15M = $5,900
$15M - $20M = $6,400
$20M - $25M = $6,900
$25M - $30M = $7,500
$30M - $60M = $8,000
$60M - $100M = $9,000
$100M - $150M = $10,750
$150M+ = $15,000
Total Amount Dues
Submit Membership Application
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