Membership Form - Regional Advisory Council - TSA G Phone - (903) 593-4722 FAX - (903) 593-5092 Mail - 100 E. Ferguson St., Ste 708, Tyler 75702 Question Title * 1. Provider / Entity Question Title * 2. First Name Question Title * 3. Last Name Question Title * 4. Title Question Title * 5. Address Question Title * 6. Telephone Question Title * 7. Cell Phone Question Title * 8. Email Address Question Title * 9. County Question Title * 10. Association Physician Trauma Coordinator HPP Coordinator EMS Provider Trauma Medical Director Multilingual (Languages) Associate Member Affiliate Primary Voting Member Contact Information: Question Title * 11. Name: Question Title * 12. Contact Number: Question Title * 13. Email: Alternate Voting Member Contact Information: Question Title * 14. Name: Question Title * 15. Contact Number: Question Title * 16. Email: 1. Have an operational base within a TSA-G county Anderson - Camp - Cherokee - Franklin - Freestone - Gregg - Harrison - Henderson - Houston Marion - Panola - Rains - Rusk - Shelby - Smith - Trinity - Upshur - Van Zandt - Wood 2. Agree to comply with RAC-G Mission and Governing Documents 3. Agree to pay annual dues in a timely manner. 4. Agree to participate in at least 75% of all quarterly meetings 5. Agree to participate in at least two (2) standard committees. For further information - please go to our website at: www.rac-g.org or call 903-593-4722 Done