Provider Application – Pay with Credit Card Please complete the form below to become a SPADD member organization or renew an expiring membership. *Note that processing fees apply when paying dues with a credit card.* Step 1 of 5 20% Demographic InformationOrganization(Required) Primary Contact / Voting Member(Required) First Last Email Address(Required)Enter the primary contact's email address here. You will have a chance to enter additional email addresses for your organization later. Enter Email Confirm Email Website Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code More About Your OrganizationIs the organization nationally accredited?(Required) Yes No Accrediting Body Renewal Date Month Day Year Is the organization certified by DBHDD?(Required) Yes No Expiration Date Month Day Year Which support(s) does your organization provide?(Required)Choose all that apply. Community Residential Alternative (CRA) Community Access Group (CAG) Community Access Individual (CAI) Pre-vocational Services Supported Employment Services Support Coordination Services State Funded Other Other support(s) not listed above: Revenue, Persons Served, and PersonnelFor the following questions, provide an unduplicated number; if you provide more than one service to an individual, only count the person once. Revenue should reflect the fiscal year previous to the year for which you are applying. For example, when applying for the fiscal year ending 2024, enter revenue for the fiscal year ending 2023.Total Number of Individuals Supported in IDD Services (Waiver, GIA, & VR funding):(Required)Total Revenue for IDD Programs/Services (Waiver, GIA, & VR funding):(Required)Total Number of Employees providing IDD Services (Full Time Equivalents):(Required) Additional Organization ContactsAs a SPADD member organization, you may add other employees so they can receive SPADD digital correspondence. Please list any additional staff names and email addresses you would like to add. Note: This field is for *new* additions; email addresses that already exist in SPADD's system will not change.Would you like to add more employee email addresses? Yes No Name First Last Email Name First Last Email Name First Last Email Dues PaymentTerms Agreement(Required)By agreeing to SPADD's membership terms, as the member organization's representative, you attest that the information entered on the SPADD Annual Membership Form is accurate and correct to the best of your knowledge. The SPADD membership year runs from July 1 through June 30. Membership terms dictate that News and Notes, SPADD Alerts, and other written communication from SPADD that is not publicly distributed is for SPADD members only. SPADD News & Notes and SPADD Alerts, are a benefit of SPADD Membership. No part of News and Notes, SPADD Alerts, or other written communication from SPADD that is not publicly distributed may be reproduced or transmitted, in any form or by any means, without prior written permission from a SPADD administrator. Login credentials to any Members Only portion of spadd.org may not be shared with any non-member organization or entity. Agreement with these terms includes authorization for SPADD to publicize the organization’s membership on the SPADD website and other digital and print marketing materials. I agree to the SPADD Member Terms1-Year Provisional Membership Level(Required) Price: Credit Card Processing Fee Total Credit Card(Required)Credit card payments are securely processed by Stripe. Once submitted, it may take up to 30 seconds for processing. During that time, do not resubmit or refresh this page to prevent duplicate charges.Card Details Cardholder Name CAPTCHA
