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

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

T