2019 Provider Member Renewal Form
Please complete this renewal form for CDPAANYS Provider Membership.
Email address *
Agency Name *
Your answer
Agency Address *
Your answer
Agency Phone Number *
Your answer
Agency Website Address
Your answer
Name and Email of Executive Director *
Your answer
Name and Email of CDPA Contact *
Communications will be directed to this person unless otherwise indicated.
Your answer
Agency's Total Annual CDPA Revenue *
CDPAANYS Annual Dues are based on the agency’s total CDPA revenue from your most recently completed fiscal year. This section must be reviewed and verified by an independent accountant or auditor who has familiarity with the applying fiscal intermediary’s records. Using the table below, please identify your agency’s total:
Name of Independent Accountant or Auditor *
Your answer
Accountant or Auditor Firm/Company *
Your answer
Attestation of Annual Dues *
Required
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