Membership Application and Registration Form RAC-R FY 2027 (9/1/26-8/31/27)
EMS Provider
Name of your Organization
*
Name of CEO or Chief
*
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from physical address)
*
P.O. Box
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employer ID Number (EIN)
*
Total number licensed EMS units staffed daily under normal operations in RAC-R Counties.
*
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Organizations Representative to the RAC
Name
*
First Name
Last Name
Title / Position
*
Email
*
example@example.com
Office Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Representative to the RAC
Name
*
First Name
Last Name
Title / Position
*
Email
*
example@example.com
Office Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact for Organization
Name
*
First Name
Last Name
Title / Position
*
Email
*
example@example.com
Office Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
EMS County of Licensure
List the County in which your agency is licensed by DSHS.
*
List the county / counties OUTSIDE your county of licensure in which you have an agreement to provide Emergency 911 or Emergency Transfer Services:
*
List the top 3 emergency management hazards in your county.
Hazard 1
*
Hazard 2
*
Hazard 3
*
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Who is authorized person to commit the organization to membership in the RAC.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature
*
Email to submitter
*
example@example.com
Continue
Should be Empty: