Willingness to Serve Application

Name(Required)

I am willing to serve the Georgia Council of Perioperative Registered Nurses in the following capacity (place check in box next to position you are running for):(Required)

Chair-Elect

Treasurer

Board of Directors

My eligibility is as follows (check all that apply):(Required)

I am an active local Chapter member or Member-at-large in the State of Georgia.

I have served actively in my chapter and am willing to support the Council’s activities including legislative, fundraising and local Chapter support.

I have been an active member of AORN for two years without a lapse in membership.

Please list local chapter activities:

Other information pertinent to qualifications (other professional organizations, education, etc.):

Home Address(Required)

City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Personal Email(Required)

Place of employment(Required)

Job Title(Required)

Work Address(Required)

City State / Province / Region ZIP / Postal Code Country

Email(Required)

Chapter Affiliation

Choose your chapter

Name

This field is for validation purposes and should be left unchanged.