Authorized Assistance Agency Form

Authorized Assistance Agency Form

Agency/Organization Information

Agency/Organization Name*

Phone*

EIN*

Address*

City*

State*

Zip Code*

Email Address*

Website

(if applicable)

Authorized Users

Individuals below are employees or representatives of the organization, church or school that will contact OPPD to either make pledges or make customer inquires.

Authorized User Name*

(first, last)

Authorized User Email Address*

Authorized User Name 2

(first, last)

Authorized User Email Address 2

Authorized User Name 3

(first, last)

Authorized User Email Address 3

Authorized User Name 4

(first, last)

Authorized User Email Address 4

Authorized User Name 5

(first, last)

Authorized User Email Address 5

If you have more than 5 names to add or update an authorized users, complete the form and email agencyupdates@oppd.com with the remaining users.

*Review the Data Sharing Policy below and check box to agree*

*Data Sharing Policy

Questions? Email agencyupdates@oppd.com or call 402-536-4131