2010 Provider Renewal Invoice

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Membership Renewal DUE UPON RECEIPT
Organization:________________________________________ Address 1:___________________________________________ Address 2:___________________________________________ City:________________________________ State: ________ Zip:_______________ Main Phone: ________________________________________ Main Fax:___________________________________________ Website:_________________________________________ List on providers.org? Yes / No (circle one) Would you like to include a Providers’ Council logo on your site? Yes / No (circle one) Renewal Contact:_____________________________________ Title:_______________________________________________ Phone: _____________________________________________ Email: _____________________________________________ CEO/ED (if other than above): __________________________ CEO/ED Email:______________________________________ Please provide us with the following information so that we may serve you better… CFO/Business Manager (name & title): _____________________________________________________ CFO Email: _____________________________________________________ Human Resources Manager (name & title): ______________________________________________________ HR Manager Email: ______________________________________________________ Please include names/emails or business cards of any other staff who should be informed of Council events. As a member of the Council, your entire agency’s staff or select members are eligible to receive our Providers’ Council Weekly eDigest to let them know about training opportunities, important public policy updates, and ways to reduce costs. Start taking advantage of this important benefit today by emailing Kevin Gilnack at kgilnack@providers.org for more information!
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2010 Providers’ Council Membership Renewal Invoice (for period 1/1/2010 to 12/31/2010)
2010 Membership Dues are due upon receipt of this notice. In order to offset the costs of additional invoicing, a late charge may be assessed if future notices are sent. Total revenue from year 2008 Form 990 (line 12): _$_______________ _____ Please enclose a photocopy of page 1 of 2008’s 990 to avoid delay in processing your membership. _____    _____    _____    _____    _____    _____    _____    _____    Annual Revenue:        Dues Amount:    < $250,000          $150    $250,000 ‐ $2,999,999          Revenue ______________________  x  .00075 = $ _____    $3M ‐ $4M          $2800    $4M ‐ $6M          $3500    $6M ‐ $9M          $4500    $9M ‐ $25M          $5200    $25M ‐ $50M         $6250    $50M +          $7500 
Please mail your check (payable to MCHSP, Inc.) with this invoice and page 1 of your 2008 Form 990 to: Providers’ Council ATTN: Membership 250 Summer Street, Suite 237 Boston, MA 02210
If special payment arrangements are needed, please contact Kevin Gilnack at kgilnack@providers.org or 617-428-3637 x124
THANK YOU for your continued membership!