2024 Provider Membership Renewal Form

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Organization Information

Thank you for your commitment to the human services sector in Massachusetts.
Renew your Providers' Council membership TODAY for January 2024 thru December 2024!

Provider Member Organization:
Please note: Your organization may be found under "T" if your agency's name starts with "The".

Did your organization's mailing/billing address change in 2023?

YesNo

Please ensure the following information is up-to-date:

Address

Suite/Building #

City

State

Zip Code

Agency Phone Number

Membership Renewal Contact

Who should we reach out to at your organization in regards to membership?

First Name

Last Name

Job Title

President / CEO / Executive Leader

First Name

Last Name

Job Title

Financial Leader / CFO

First Name

Last Name

Job Title

HR Director / HR Leader

First Name

Last Name

Job Title

Public Policy Director

First Name

Last Name

Job Title

Communications Director

First Name

Last Name

Job Title

Learning / Training Director

First Name

Last Name

Job Title

Approximate number of employees:

Full Time:

Part Time:

Volunteer:

Primary Funding Agency/Source (ex. DDS)

Other Funding Source:

Annual Revenue (ex. $2,050,100 from line 12 of your most recent 990):
Please attach a copy of the first page of the 990.

First Page of your most recent 990

Additional Financial Statements

Annual Revenue Range (based off line 12 of most recent 990). This will be verified upon receipt of 990 information and payment received. We will reach out if there is a discrepancy.

2024 Membership Dues:

Please make checks payable to the Providers' Council

Mail payment to 100 Crossing Blvd Suite 100, Framingham, MA, 01702

If you require an invoice for processing or would like to submit payment via an ACH transfer, please contact info@providers.org with your request.

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Contact Information

2024 Provider Membership Renewal Form

Organization Information

Provider Member Benefits