Pennsylvania Association of PeriAnesthesia Nurses

                                     

      Outstanding Achievement Award Nominee 

STEP TWO:  To be completed by the nurse being 
                  nominated.  Please avoid abbreviations. 

Name (include middle name)
_____________________________________________________
Home address _____________________________________________________
City, State, Zip
_____________________________________________________
Employer 
_____________________________________________________
Employer Address 
_____________________________________________________
City, State, Zip
_____________________________________________________
Current Position
_____________________________________________________
Immediate Supervisor
_____________________________________________________
Entry Nursing Degree from
_____________________________________________________
( ) AD   ( ) Diploma ( ) BSN    City_____________ State___

Additional Degree(s): (list degree and institution) ______
_____________________________________________________
_____________________________________________________

Professional Certification(s) __________________________
_____________________________________________________

Professional Organizations membership(s), honors, awards _____________________________________________________
_____________________________________________________
_____________________________________________________

I agree to be considered for the Outstanding Achievement Award sponsored by the Pennsylvania Association of PeriAnesthesia Nurses (PAPAN).  I agree to participate in the awards progam, if chosen.  I understand that the Awards Committee may contact my present employer, and I authorize said employer to release information pertinent to such a request.

Signature ___________________________ Date __________

Mail to Membership Chair Fran Blatchley
215 Front Street, Box 101
New Berlin, PA 17855
Postmarked no later than February 29, 2008

Info@papanonline.org

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