 |  |  |  |  |  |  |
| . |
| Georgia Association of PeriAnesthesia Nurses www.GA-PAN.org |
GAPAN PERIANESTHESIA NURSE OF THE YEAR APPLICATION PLEASE TYPE OR PRINT LEGIBLY Name and Credentials _________________________________________________________________ Address __________________________________________________________________________ City _________________________ State ____________ Zip ________________________________ Telephone (home) _______________________ Telephone (work) _______________________________ Email address ______________________________________________________________________ Perianesthesia Nursing Experience: Employer _________________________________________________________________________ Address __________________________________________________________________________ Position ____________________________ Date of Hire ____________________________________ Supervisor Signature _________________________________________________________________ Falsification or failure to follow all instructions will disqualify this applicant. Application Process The following information must be submitted: 1. A completed application form. 2. A copy of your ASPAN membership card. 3. A brief CV – no more than three pages – include professional experience, education level, and participation in state or national nursing organizations. 4. Supporting documentation of your contribution to perianesthesia nursing. (See next page for Activity Verification form.) Mail 5 (five) copies of all of the above information to: Susan Andrews 4454 Whisperwood Drive Martinez, GA 30907 DEADLINE: All applications must be postmarked on or before September 5 , 2008 – NO EXCEPTIONS. *************************************************************************************************************************** GAPAN PERIANESTHESIA NURSE OF THE YEAR ACTIVITY VERIFICATION I verify that _____________________________ has conducted the following activity: ________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________________________________________________ _________________________________ _______________ ____________________ Supervisor/District Officer Signature Telephone Number Date You may copy this form as needed. |
*****************************************************************************************************************************************************
GAPAN PERIANESTHESIA NURSE OF THE YEAR
ACTIVITY VERIFICATION
I verify that _____________________________ has conducted the following activity:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
_________________________________ _______________ ____________________
Supervisor/District Officer Signature Telephone Number Date
You may copy this form as needed.
GAPAN PERIANESTHESIA NURSE OF THE YEAR
ACTIVITY VERIFICATION
I verify that _____________________________ has conducted the following activity:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
_________________________________ _______________ ____________________
Supervisor/District Officer Signature Telephone Number Date
You may copy this form as needed.
*****************************************************************************************************************************************************
GAPAN PERIANESTHESIA NURSE OF THE YEAR
ACTIVITY VERIFICATION
I verify that _____________________________ has conducted the following activity:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
_________________________________ _______________ ____________________
Supervisor/District Officer Signature Telephone Number Date
You may copy this form as needed.
GAPAN PERIANESTHESIA NURSE OF THE YEAR
ACTIVITY VERIFICATION
I verify that _____________________________ has conducted the following activity:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
_________________________________ _______________ ____________________
Supervisor/District Officer Signature Telephone Number Date
You may copy this form as needed.