Member Acknowledgement Form

Thank you for becoming a member of the Opioid Treatment Providers of Georgia. In order to ensure that you, the person responsible for Board Membership, is aware of the responsibilities your position entails we request that you complete this form and return it with your dues payment.

If you are not currently a member of OTPG but would want to partner with fellow opioid treatment providers in Georgia, please contact us about membership.

  • The above named shall represent my organization on the OTPG Board of Directors. I understand if this person is unable to attend the meeting, I can appoint a temporary attendee with voting powers by notifying a member of the OTPG Executive Committee in writing.
  • (if different than Sponsor)
  • Please remember to submit your signature as it is required
  • MM slash DD slash YYYY