Willingness to Serve NCAPAN Form

The North Carolina Association of PeriAnesthesia Nurses continues to increase its membership and strengthen its influence within the workplace. The Association asks PeriAnesthesia nurses to volunteer their leadership abilities to continue the progress of our specialty. Please fill out this form indicating how you would be willing to contribute to the growth of the NCAPAN.

Name: ___________________________________________________
            MS____ BSN_____RN_____LPN_____CPAN_____CAPA_____

Address: _________________________________________________

_________________________________________________________

Telephone (H) __________________  (W) ______________________

Email: ___________________________________________________

Employer: ________________________________________________
Position: _________________________________________________

Member Affiliation: ASPAN/NCAPAN _______District:______________
            Other: ____________________________________________
Number of years in PeriAnesthesia Nursing ______________________

Please attach qualifications to include:
            Areas of experience                     Community/Project participation
            Organizational involvement            Community Contributions
            Family                                        Hobbies
            Dreams
            A short paragraph related to: What I have to offer this position

I would be interested in running for the following position(s) on the Board of Directors:
            ___ Vice President/President Elect
            ___ Secretary
            ___Treasurer
            ___Member-At-Large

Please indicate your interest in serving NCAPAN in any of the following ways:
            ___ Bylaws/Policy and Procedure   ___ Public Relations
            ___ Finance                                ___ Marketing
            ___ Nominations                         ___ Education
            ___ Research                              ___ Strategic Planning

Please mail your qualifications form to the current NCAPAN Vice President/President Elect by March 1.

The North Carolina Association of PeriAnesthesia Nurses