PAPAN -- Grant to Attend ASPAN National Conference Form

      Pennsylvania Association of PeriAnesthesia Nurses

                                             
   Grant to Attend ASPAN National Conference Application

Name: _______________________________________________
Address: _____________________________________________
Telephone (H) __________________ (W) _________________
E-mail address: ______________________________________
Years in Nursing ____ Years in PeriAnesthesia Nursing ___

Active employment in PeriAnesthesia nursing:
   Area of practice: ____________________________________
   Employer address: __________________________________
   Manager signature: _________________________________
   Certifications: ______________________________________

Reason for request: (100 words or less; may attach typed
document)
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________

ASPAN/PAPAN number: ________________________________
Number of years of active SPAN/PAPAN membership: ____
PAPAN member contributions: (list and include year)
   Officer _____________________________________________
   Board Member _____________________________________
   Committee Chair ___________________________________
   Committee Member ________________________________
   New Member Recruitment ___________________________
PAPAN (PeriAnesthesia PRIDE) conference attendence:
   Conference/year__________   Conference/year ________
   Conference/year__________   Conference/year ________

Professional awards, presentations, publications:________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________

Mail application to Frances Blatchley, Membership Chair
215 Front Street, Box 101, New Berlin, PA 17855
Info@papanonline.org

Must be mailed/postmarked no later than February 28, 2007
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Copyright 2005 Pam Carrion. All rights reserved.