Phone - (903) 593-4722 FAX - (903) 593-5092 Mail - 100 E. Ferguson St., Ste 708, Tyler 75702

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* 1. Provider / Entity

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* 2. First Name

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* 3. Last Name

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* 4. Title

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* 5. Address

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* 6. Telephone

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* 7. TAX ID - EIN Number

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* 8. Cell Phone

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* 9. Email Address

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* 10. County

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* 11. Association

Primary Voting Member Contact Information:

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* 12. Name:

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* 13. Contact Number:

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* 14. Email:

Alternate Voting Member Contact Information:

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* 15. Name:

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* 16. Contact Number:

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* 17. 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

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