* 1. Organization/Individual Name

* 2. Adress

* 3. City

* 4. Zip

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

* 6. Phone #

* 7. Fax #

* 8. Email address

* 9. Cell phone capable of receiving text messages

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

* 11. Phone #

* 12. Fax #

* 13. Email address

* 14. 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 $100

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

* 16. Payment

* 17. 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

* 18. Printed name of authorized signor

* 19. Date

* 20. Title

* 21. Texas Hospital/provider license #

* 22. Expiration date

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