2023 Affiliate Member Form

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Please complete this form to join CDPAANYS as an Affiliate Member.

Membership as an Affiliate Member is $1,000 and is valid for one calendar year after the join date. Upon receipt of this form, an invoice will be emailed to you.

Affiliate Members will be added to an exclusive email listserv. Your logo will be listed on CDPAANYS' website and your company information will be listed in a searchable directory. Your organization will also receive member discounts to all CDPAANYS events, and are given opportunities to showcase your organization's product or service to our provider member network.

Organization Name *

Contact Name & Title *

Mailing Address *

Phone Number *

Agency Website Address *

Does your organization offer CDPA services? *

If your organization is a CDPA provider, you will be asked to complete the Provider Member application. Affiliate Organizations may not be fiscal intermediaries or licensed home care agencies.

Yes

Is your organization affiliated with a Fiscal Intermediary? *

Yes

If yes, please explain:

Attestation of Intent to Join *

I want to become a member and help support CDPAANYS and the Consumer Directed Personal Assistance program. I attest that the information provided above is accurate to the best of my knowledge and that I am authorized to join CDPAANYS on behalf of my organization.

I attest that the information provided above is accurate to the best of my knowledge and that I am authorized to join CDPAANYS on behalf of my organization.

Required

Date *

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