Nebraska Association of Service Providers

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Membership Application

Nebraska Association of Service Providers

1200 Libra Drive, Suite 100, Lincoln, NE 68512
(402) 320-5319 admin@neserviceproviders.org

An association must complete this application form and be approved by the NASP Executive Committee before they may participate as a member of the Association. Membership is open to community-based agencies and organizations contracting with the State of Nebraska to provide services and supports to persons with intellectual/developmental disabilities.

Organization Name

Address

If your organization provides services in multiple locations in Nebraska, please provide all additional mailing addresses, along with names and email addresses for the contact person(s) in the Additional Information box below.

Additional Information

Phone Number

Fax Number

Organization Website

Year Founded/Incorporated

Executive Director

Executive Director Email Address

Primary Contact for Agency

Title

Primary Contact Email Address

Phone

Accreditation/Licensure

Exp Date

Total Number of Employees (include all locations in Nebraska)

Total Number of Persons Served (include all services in Nebraska)

Total Annual DDD Revenue (most recent year for Nebraska)

Indicate the variety of services currently being provided by your organization in Nebraska:

Residential Services

Day Services

Employment Services

Respite Services

Executive Director Electronic Signature

Date

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