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.

Affirmation Of Terms:*
Click To Read The OTPG By-Laws
- I have read the Opioid Treatment Providers of Georgia By-laws and understand my responsibility to the organization.
- I will follow the treatment guidelines as described in Article V of the OTPG By-Laws.
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.

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.
Clinic Name*
Facility Address*
Street Address City State ZIP Code
Printed Name of Sponsor*
First Last
Printed Name of Appointed Board Member
(if different than Sponsor)
First Last
Signature of Sponsor*
Please remember to submit your signature as it is required
Date*
MM slash DD slash YYYY
Email*