ADDP Membership Application

Please complete this form and return with dues payment to the address below.

Organization: ___________________________________________________________________________

Address: ________________________________________________________________________________

City, State, ZIP: __________________________________________________________________________

Telephone: ______________________________________________________________________________

Federal Taxpayer I.D. Number: ______________________________________________________________

Executive Director/President/CEO: _________________________________________________________

Title:____________________________________________________________________________________

Telephone and Extension: ___________________________________________________________________

Fax: ___________________________________________ E-mail:__________________________________

ADDP Contact (if different): _______________________________________________________________

Title:____________________________________________________________________________________

Telephone and Extension: __________________________________________________________________

Fax: ___________________________________________ E-mail:__________________________________

Principal DMR Purchasing Region: ________________________________________________________

Number of Employees: _________________ Number of FTE's:__________________________________

Organization's Total Operating Budget: ____________________ DD Services Budget: _____________

Membership dues are based on your organization’s developmental disabilities services budget.

Please check the appropriate budget based on your total DD services.

Dues DD Services Budget

? $600. Budget under $500,000.

? $1200. Budget between $500,000. and $1 million

? $1740. Budget between $1 million and $3 million

? $2040. Budget between $3 million and $5 million

? $2400. Budget between $5 million and $7 million

? $3000. Budget between $7 million and $10 million

? $3600. Budget between $10 million and $15 million

? $4200. Budget over $15 million

? Enclosed is check payment in the amount of $ .

Please charge my credit card: ? VISA ? MasterCard

Card Number: ____________________________________________________________________________

Expiration Date: __________________________________________________________________________

Cardholder's Name: _______________________________________________________________________

Billing Address: __________________________________________________________________________

Cardholder's Signature: ____________________________________________________________________

Mail membership form with payment to: ADDP, 217 South Street, Waltham, MA 02453

Faxes accepted for membership paid by CREDIT CARD ONLY. Fax to: 781-891-0429.