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 (your instructions may be submitted in “comments” space 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

Comments/instructions