SER WOCN - Consent to Serve Form

2012 Consent to Serve Form

Criteria:

Active member of SER WOCN
Member for one year immediately prior to the election

All fields are required

First Name:

A name is required.

Last Name:

A name is required.

Address:

Address is required.

City:

A city is required.

State:

Select State.Please select an item.

Zip Code (5 digit): A 5 digit zip code is required.Invalid format.

Phone with area code: A phone number is required.

Phone Type:

Home

Work

Cell

Select type of phone number.

Email:

Valid email address required.Vaild email address is required.

Name of Nursing School:

Name of Nursing School.

WOC/ET NEP:

A value is required.

WOCN member since (YYYY): A four digit year is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.

Select OFFICE desired: Please select a valid item.Please select position desired.

Your Qualifications/Goals for office:

A value is required.

By checking this box, I confirm that I understand the duties and responsibilities of the office for which I am submitting my name. If elected, I agree to fulfill the duties of the office to the best of my ability .