Skip to content
Enriching the lives of people with disabilities.
Home
About Us
Our Focus
Our Mission
Our Pledge
Our Members
Our Board of Directors
Join Us
Become a Member
Events
2024 CPAO Conference
2023 Conference Highlights
Conference Archives
Helpful Links
Get in Touch!
Enriching the lives of people with disabilities.
Navigation Menu
Navigation Menu
Home
About Us
Our Focus
Our Mission
Our Pledge
Our Members
Our Board of Directors
Join Us
Become a Member
Events
2024 CPAO Conference
2023 Conference Highlights
Conference Archives
Helpful Links
Get in Touch!
Home
»
CPAO Membership Application
CPAO Membership Application
CPAO Membership Application
Agency Name
*
Membership Type You Are Applying For :
*
Provider
Professional
Associate
Contact Name
*
First
Last
Email
*
Enter Email
Confirm Email
Phone
*
Fax
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Types of Services Provided (Check All That Apply)
*
A & D Services
I/DD Services
Case Management Services / Brokerage
Mental Health Services
Children Services
Residential Services
Counseling Services
Senior Services
DD Services
Training / Technical Support Services
Employment Services / DSA Services
Number of Individuals Supported:
*
Number of DSP Represented:
*
Total Number of Employees:
*
Number of Physical Locations/Sites:
*
Please List The Location(s) of Services Provided:
Click on the + button to add additional rows/Locations
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?
*
Today's Date
*
MM slash DD slash YYYY
The membership process is initiated upon receipt of application to the Membership Committee. The committee will determined whether or not to recommend membership to the Board of Directors. The Board of Directors determines whether to pass the application on to the full membership for final approval. Provider membership dues are based on the gross revenue from the State of Oregon for contracted services. Professional and Associate dues are based on a flat rate. Dues are paid in full annually, each January. New member dues are prorated starting the month they join.
CAPTCHA
Scroll