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Agency Registration Form

Thank you for your interest in NYSACRA's Member's Only Section. There are many benefits to membership. Click on the following link to see what NYSACRA can offer to you. Benefits of Membership. The information you provide is used to develop your agency profile. This profile is used in our membership directory, ensures that mailings reach the proper individuals and places your agency in the appropriate membership category.

NYSACRA is adding new services and information to its website continuously. However, many of these services will be available online only through this Members Only section, such as News & Views, Newsletters, Reports, Committee Meeting Minutes, and much more. Every employee of a Member Agency is welcome to join. Click here to see if your agency is a NYSACRA Member. If your agency is already listed then please proceed to the Member Registration form.

Please complete the information below and click "Submit".If you prefer, you may fill it out, print it and fax it to 518-449-1509.

Again, thank you for your interest and support.

Agency Name
Address
City/State/Zip
Website
Email
Phone
Fax
Primary Contact
First Name
Last Name
Title
Address
City/State/Zip
Email
Phone
Fax
Secondary Contact
First Name
Last Name
Title
Address
City/State/Zip
Email
Phone
Fax
Executive Director
First Name
Last Name
Title
Address
City/State/Zip
Email
Phone
Fax
Fiscal Officer
First Name
Last Name
Title
Address
City/State/Zip
Email
Phone
Fax
Ed/Training
First Name
Last Name
Title
Address
City/State/Zip
Email
Phone
Fax
Quality Assurance
First Name
Last Name
Title
Address
City/State/Zip
Email
Phone
Fax
Service Coordination
First Name
Last Name
Title
Address
City/State/Zip
Email
Phone
Fax
Legislative
First Name
Last Name
Title
Address
City/State/Zip
Email
Phone
Fax
Human Resources
First Name
Last Name
Title
Address
City/State/Zip
Email
Phone
Fax
Community Services Provided
number of sites         number of people served
ICF
CR
SUPP
IRA
ISS
WAIVER
ISE
RES HAB
DAY HAB
SUPP WORK
FAMILY SUPP
FAMILY CARE
RESPITE
MSC
Number of Full-Time Employees
New Development Planned/Time Frame
Indicate the total annual MR/DD revenue for your agency's Community Living Services listed above $
Please check any other services your agency provides
Describe any service/products your agency markets that would be beneficial to other members
Please check any other services your agency provides
Prepared By
Preparer's Email

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