Nomination/resignation Form - Iowa Emergency Response Commission

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Iowa Emergency Response Commission
Nomination/Resignation
Local/Regional Emergency Planning Committee Membership
Name of County/Region:
Name of Person
:
Title
:
Company Name
:
Address
:
(Street/PO Box)
(City)
(ZIP)
Work Phone
E-Mail
:
:
Please check the group you represent: (check more than one if necessary)
☐ Elected State or Local Official
☐ Hospital Personnel
☐ Law Enforcement Personnel
☐ Emergency Management Personnel
☐ Fire Fighting Personnel
☐ Transportation Personnel
☐ First Aid Personnel
☐ Broadcast or Print Media
☐ Health Personnel
☐ Community Group
☐ Local Environmental Personnel
☐ Owner/Operator of Facility Subject to
Section 302(c))
☐ Other
NOMINATION selection:
☐ Member
☐ Chair
☐ Vice-Chair
REAPPOINTMENT for
Years
Elected
☐ Chair
☐ Vice-Chair
RESIGNATION
:
☐ Member
☐ Chair
☐ Vice-Chair
Signature
Date
IERC form 6/2015

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