AORN of San Diego County

Willingness to Serve

Applicant Information

Full Name:	Date:
Last	First	M.I.

Address:
Street Address	Apartment/Unit #

City	State	ZIP Code

Phone:	Email:

RN License:	State:

Credentials:	Are you currently CNOR Certified?	YES

NO

Employment Information

Current Employer:

Current Position:

Total Years of OR Experience:

Educational Information

School Name:	Degree:

School Name:	Degree:

School Name:	Degree:

School Name:	Degree:

AORN Membership

AORN Membership ID:	How many years have you been an AORN member?

Is AORN of San Diego County your Primary Chapter?	YES

NO

Have you maintained your AORN membership continuously for one year?	YES

NO

Within the past 12 months, how many Chapter Meetings have you attended?

How many times have you attended AORN Global Surgical Conference and Expo?

Have you ever served as a Chapter Delegate or Alternate?	YES

NO

How many times?	Delegate:	Alternate:

Have you ever served on the Board of Directors for your local Chapter?	YES

NO

Position:	Date Served:

Have you ever served as a Committee Chair for your local Chapter?	YES

NO

Committee:	Date Served:

Have you ever served as a Committee Member for your local Chapter?
YES

NO

Committee:

Date Served:

Have you ever served AORN at the National Level?
YES

NO

Position:

Date Served:

Have you ever served on other Organizations?
YES

NO

Position:

Date Served:

Please include any additional AORN Chapter, AORN National, or other Organizational involvement.

Position Running For

Position:

Please include a brief statement in 50 words or less why you are seeking this position, and what qualifies you for this position. This statement will be posted on aornsandiego.org.

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. Print this form, sign and date it, and submit it with all other required documents to the Nominating Committee Chair.

Signature:
Date:

2

Employment application

Jon

2017-01-16

Microsoft Corporation