Question Title

* 1. Organization/Individual Name

Question Title

* 2. Adress

Question Title

* 3. City

Question Title

* 4. Zip

Question Title

* 5.  Primary Designated Representative's Name - One Per Organization

Question Title

* 6. Phone #

Question Title

* 7. Fax #

Question Title

* 8. Email address

Question Title

* 9. Cell phone capable of receiving text messages

Question Title

* 10.  Alternate Designated Representative's Name - One Per Organization

Question Title

* 11. Phone #

Question Title

* 12. Fax #

Question Title

* 13. Email address

Question Title

* 14. What kind of continuing education courses, topics, or content that is not readily available in our area would be most beneficial to your agency/hospital through RAC-sponsored training courses, seminars, workshops, etc.? 
List according to preference

Question Title

* 15. MEMBER CLASSIFICATION & FEES 
According to BCRAC Bylaws, annual dues (September - August) are assessed based on your classification with 
the Texas Department of State Health Services.  Please check one of the following, filling in your calculated fees
based on your associated bed/ambulance/asset information as applicable:
VOTING MEMBERSHIP $200

Question Title

* 16. Associate (Non-voting) Members:  $50

Question Title

* 17. Payment

Question Title

* 18. I/my organization acknowledge(s) responsibilities as a member and essential component of the emergency healthcare system
established by the State of Texas for the sixteen counties comprising Trauma Service Area - D.  I affirm its/my, willingness to comply, as appropriate, with state and/or regional guidelines, obligations and by-laws as presented by the Big Country Regional Advisory Council (BCRAC) and its Board, generally found at WWW.BigcountryRAC.org

Question Title

* 19. Printed name of authorized signor

Question Title

* 20. Date

Question Title

* 21. Title

Question Title

* 22. Texas Hospital/provider license #

Question Title

* 23. Expiration date

T