Agency Membership Application Form

Please complete the following form. Click Submit to send your membership information to the OALPRP. You will be contacted regarding your membership.

* Note that agency membership includes all personnel working within your agency. Please supply a list of personnel; designate the person authorized to vote for the agency.

Your Name:

Email Address:

Agency Name:

Enter Membership Year:

Official Delegate:

Agency Address:

Agency City: State: ZIP Code:

Daytime Phone: Fax:

Additional Personnel:

Person Authorized to Vote:

Comments: