EMT member:

Date:

_____ Opt In to full participation on the rulemaking team (may assign a representative to participate)

Designated contact/phone: ___________________________________________.

_____ Opt In to participate through a side agreement, and will submit a proposed agreement to the

contact above. The side agreement identifies your interests and how you would like to be involved in the process (may be completed below). Please also specify whether you want to complete concurrence review on the:

Y N Notice of proposed rulemaking package

Y N Final rulemaking package

Designated contact/phone: ____________________________________________.

_____ Opt Out: Will not participate in this rulemaking process