Missouri State Council by vp8ko7wG

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									                                 Committee Application 2012
                              MISSOURI ENA STATE COUNCIL
      Please complete a separate application for each committee chair or co-chair position for which you apply.
        Nursing &                Combined Clinical                       Communications
        Advanced                 Conference & Education                   Chair
        Practice                  Chair                                  Newsletter Co-Chair
          Chair                  Co-chair                               Website Co-Chair
          Co-Chair               Member                                 Member
          Member
        Disaster                 Course Operations                       Marketing/PR
        Preparedness              Chair                                  Chair
          Chair                  TNCC Co-Chair                          Co-Chair
          Co-Chair               ENPC Co-Chair                          Member
          Member                 CATN Co-Chair


         Injury                  Governmental Affairs                    Membership
         Prevention               Chair                                  Chair
          Chair                  Co-chair                               Co-Chair
          Co-chair               Member                                 Member
          Member

        Compliance
        Committee
          Chair
          Co-chair
          Member




Name: ________________________________________________________________________

Address: ______________________________________________________________________

Home Phone: _____________________________ Work Phone: ________________________

Cell: __________________________ E-mail: ________________________________________

Place of Business: ______________________________________________________________

Business Address:
______________________________________________________________

City: ______________________________ State: ________________________ ZIP: _________

Years as a nurse_______      As an ED nurse _ ________ as a trauma or ICU nurse________

How many years as an ENA member___________ Name of local chapter________________
Missouri ENA State Council                                                Page 2
Committee Application 2012


Chapter President: ______________________________________________________________

Number of chapter meeting attended: 2010__________________ 2011__________________

Number of State Council meetings attended: 2010____________ 2011__________________

Advanced degrees:         BSN                    MSN          MA          MBA

                          PhD                    Other


Advanced
Certificates/Awards:      CATN                   CEN          CCRN        ENCARE



    ENPC                 ENPC-I                 FAEN         TNCC        TNCC-I


    CATN Course          CPSTechnician          ATCN               ATCN-I
     Director
                          CPST Instructor

    TNS


ENA Member #:                             TNCC-I#:______________________

 ENPC-I #:                   CEN #: _______________ CCRN #:________________

TNS License #:

What committee goals would you establish as a chair or co-chair? List 3

1.___________________________________________________________________________

2.___________________________________________________________________________

3.___________________________________________________________________________

How would you accomplish these goals?

____________________________________________________________________________

____________________________________________________________________________
How would you measure the goals?




Are you willing to attend 75% of the State Council meetings? ___ Yes ___No

Will you be able travel as needed to promote and support the activities of the committee?
___ Yes ___ No

Do you have support from your work supervisor to attend State Council ENA MEETINGS?
and complete the work of the committee? ___ Yes ___No ___Don‘t know at this time

Any additional information you wish to share:




Signature                                                                  Date
A copy of your resume/CV must be submitted with the Committee Application.
All applications must be received no later than Nov. 1, 2011

Mail to:      Tony Mitchell
              twmitchell55@att.net (preferably)
              13424 Jay Dr
              Neosho, Missouri 64850-7836

								
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