BUTLER COUNTY EMS TEAM RESIGNATION

Current Butler County EMS Team members are requested to complete the following form when leaving the Butler County EMST. Upon submission of this form, you will no longer be eligible to participate in EMST emergency responses, training courses, and other EMST activities.

Today's Date *
Your FIRST Name: *
Your LAST Name: *
Your Email *
Which Butler County emergency services department are you currnetly affiliated with? (Check all that apply) * Andover Fire/Rescue Dept. Andover PD Atlanta Fire Dept. Augusta Dept. of Public Safety Benton Fire Dept. Benton PD Burns Fire Dept. Disaster Medical Support Unit (Butler Co.) Emergency Communications (Butler Co.) EMS (Butler Co.) Reserve/Volunteer EMS (Butler Co.) Paid Staff Cassoday Fire Dept. CERT (Butler Co.) Douglass Fire Dept. El Dorado Fire Dept. El Dorado PD Emergency Management (Butler Co.) Fronteir Fire Dept. Kansas Medical Center Latham Fire Dept. Leon Fire Dept. PK Safety Potwin Fire Dept. Rescue Squad (Butler Co.) Rose Hill Fire Dept. Rose Hill PD Sheriff's Dept. (Butler Co.) Susan B. Allen Hospital Towanda Fire Dept. Whitewater River Con. Fire Dist. Other
If "Other" please specify
Which BCEMST agency was your primary agency?	*	Select Andover Fire/Rescue Dept. Andover PD Atlanta Fire Dept. Augusta Dept. of Public Safety Benton Fire Dept. Benton PD Burns Fire Dept. Emergency Communications (Butler Co.) EMS (Butler Co.) Reserve/Volunteer EMS (Butler Co.) Paid Staff Cassoday Fire Dept. CERT (Butler Co.) Douglass Fire Dept. El Dorado Fire Dept. El Dorado PD Emergency Management (Butler Co.) Fronteir Fire Dept. Kansas Medical Center Latham Fire Dept. Leon Fire Dept. PK Safety Potwin Fire Dept. Rescue Squad (Butler Co.) Rose Hill Fire Dept. Rose Hill PD Sheriff's Dept. (Butler Co.) Susan B. Allen Hospital Towanda Fire Dept. Whitewater River Con. Fire Dist. Other
Reason for leaving the EMST? (not required)
Please carefully review all of the information above for accuracy BEFORE pressing the "Submit" button.