KYEM Form 430 Quarterly Active Membership List



KENTUCKY DIVISION OF EMERGENCY MANAGEMENT

RESCUE SQUAD QUARTERLY ACTIVE MEMBERSHIP LIST | |

|Name of Rescue Squad:       |State Fiscal Year:       |

|County:       |Kentucky Emergency Management Area:       |

| | | | |

|Check Quarter: | |First Quarter | |

| | |(Jul/Aug/Sep) | |

| 1.       | |19.       | |

| 2.       | |20.       | |

| 3.       | |      | |

| 4.       | |       | |

| 5.       | |       | |

| 6.       | |       | |

| 7.       | |       | |

| 8.       | |       | |

| 9.       | |       | |

|10.       | |       | |

|11.       | |       | |

|12.       | |       | |

|13.       | |       | |

|14.       | |       | |

|15.       | |       | |

|16.       | |       | |

|17.       | |       | |

|18.       | |       | |

|*Check block if member belongs to a secondary rescue squad(s). |

| Submitted By: | |Date: |      | |

| Chief Rescue Officer Signature |

|Submit completed report to: Local Emergency Management Director and Division of Emergency Management Area Manager. |

|Local Emergency Management Director: | |Date: |      | |

|Division of Emergency Management Area Manager: | |Date: |      | |

| |

DO NOT LIST MEMBERS WHO ARE INACTIVE OR DECEASED. USE ADDITIONAL SHEETS IF NEEDED.

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