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Instructions: Mark all appointed/elected positions in which you may be interesed in serving.
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Board of Directors
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Committees
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Cabinets
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Entities
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My Specialty
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Present: State Nurse Association
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Office/appointment/activity, include term (from/to)
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Past: State Nurse Association
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Office/appointment/activity, include term (from/to)
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Present Constituent Association
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Office/appointment/activity, include term (from/to)
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Past: Constituent Association
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Office/appointment/activity, include term (from/to)
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Present: Bargaining Unit
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Office/appointment/activity, include term (from/to)
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Past: Bargaining Unit
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Office/appointment/activity, include term (from/to)
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Additional volunteer information you would like to provide:
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Reason you should be elected or appointed and how you would contribute to the position. *
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Place of primary employment (mark all that apply)
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Other (describe)
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Current position or role (mark all that apply)
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Other (describe)
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Highest level of education (choose only one)
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Other (describe)
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Computer access
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Can you open e-mail attachments?
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Primary nursing specialty
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Can you send email attachments?
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Computer operating system
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Work status
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How many years have you praticed as an RN?
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Office/position applying for: *
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Date submitted
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Elected
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Appointed
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Name *
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Credentials (RN, MS, PhD, etc...) *
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Street address *
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City *
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State *
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Zip Code *
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Home phone number *
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Work phone number
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Cell phone number
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E-mail address
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Present employer
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