Affiliate Membership Enrollment

INSTRUCTIONS:  Please complete all sections of this form in order to enroll as an OACB Affiliate Member. Membership enrollment forms will be processed and invoiced immediately, with payment due within 30 days of receipt. All checks should be made payable to OACB.  Unfortunately, we do not accept credit card payments at this time. 

Questions about this form should be directed to Lora Morrison (lmorrison@oacbdd.org) or call 614-579-4015.  Thank you for becoming an OACB Affiliate Member!  We look forward to serving you.

 
Please select your preferred Affiliate Membership level:

 

Part 1: Tell us about yourself
Your Name:
Company Name:
Email Address:
Title

 

Part 2: Tell us about your organization
Your Organization Address:
City:
State:
ZIP Code:
Your Phone Number:
Alternate Phone Number:
 
What type of business is this and how does this relate to Ohio County Boards of DD?
 
Please list any other information that you would like to include.