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Organization: *
Address: * Address2:
City: * State:
Zip Code: * E-mail: *
  Executive Director/CEO:  
First Name
Last Name		 * * E-mail: *
  Business Manager/CFO:  
First Name
Last Name		 * * E-mail: *
  HR Manager:  
First Name
Last Name		 * * E-mail: *
Website:
  Number of Staff:  
Full Time: Part Time:
Volunteers:
  Tell Us:  
How did you
hear about us:
Reason(s) for Joining:
 
Funding Sources: (Check Primary Purchasing Agent)
DMH
DMR
DPH
DSS
DTA
DYS
 EEC
MCB
MCDHH
MRC
Other
 
Dues Calculation:  
Annual Revenue
(Line 12 of your most recent 990
Attach a copy)
 
Budget Category
$250,000 (dues = $150)
$250,000 - 2,999,999(annual revenue x $.00075)
$3M-4M (dues = $2,800)
$4M-6M (dues = $3,500)
 $6M-9M (dues = $4,500)
$9M-25M (dues = $5,200)
$25M-50M (dues = $6,250)
$50M+ (dues = $7,500)
 
Would you like a link to your website posted on www.providers.org?
Yes

Please make checks payable to:
MCHSP, Inc.

Mail checks to:
Providers' Council
250 Summer Street, Suite 237
Boston, MA 02210.

Note: Dues are not a deductible as a charitable contribution.
(Membership lasts for the calendar year: January through December)

Private Provider