New York Alliance for Inclusion Innovation - Agency Membership Application

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Agency Membership Application

Thank you for your interest in a New York Alliance membership. We ask that you provide us with information about your agency so that we may be a strong and respected advocate for your agency and the people you support. Our strength is found in the diversity and depth of our member organizations. Your membership enables New York Alliance to build strong coalitions and engage key stakeholders to advocate for all people with disabilities. For all membership related matters, please contact Susan Kittle at skittle@nyalliance.org or by calling 518-795-3590.

* Agency Name

OPWDD Corp Code

* Agency Street Address

* City

* State

* Zip

* Phone

Fax

* Email

* Website

* County(ies) in which your agency provides services

Primary Contact Information

* First

* Last

* Title

* Administrative Office Address

* Administrative Office City

* Administrative Office State

* Administrative Office Zip

* Administrative Office Phone (if applicable, please include extension)

Administrative Office Fax

* Administrative Office Email

Agency Services Provided

Check all that apply.

Other Services / Additional Information

* Number of People Supported

* Number of Full Time Employees

* Number of Part Time Employees

* Indicate the Total Annual OPWDD Revenue from Your Agency's Services

* Area of Expertise

Other Information (check all that apply):