National Nurses United

Consent Form:2009 10/27/09 9:45 AM Page 35 2009–2011 CNA/NNOC Committee Positions CNA/NNOC members in good standing are hereby notified and encouraged to submit their names as candidates for the following committee positions to be filled by appointment. All members in good standing seeking a position shall file a consent-to-serve, including a list of organizational experience, present employment, and position. Such forms for consents-to-serve are avail- CANDIDATE FOR: able from and should be mailed to the CNA/NNOC Administrative Office, Attention: Appointments, 2000 Franklin St., Oakland CA 94612. This form must be postmarked on or before Nov. 30, 2009. Please complete all sections of the form. Faxes will not be accepted, as an original signature is required. Terms are for the 2009-2011 biennium. Consent-to-Serve Form J Political action committee (PAC): The PAC consists of members and staff who screen and endorse candidates running for office based on their positions on a wide range of issues, from patient advocacy and workplace safety to women's and workers' rights. J Legislative-regulatory committee: Working with government relations staff, the leg-reg committee sets policy for CNA/NNOC positions on legislation and regulatory agency matters, such as wage-and-hour rules and nurse-to-patient ratios. Please check contact preferences J Mail J Phone J E-mail Name (please print) ____________________________________________________________________________________________________________________ Address (Home) ______________________________________________ City ________________________________Zip ________________________________ Phone (Home) ( ) ________________________________ (Cell) ( ) ____________________________ E-mail _________________________________ Employer ____________________________________________________ City _____________________________________________________________________ Department _________________________________________________ Shift _____________________________________________________________________ RN EXPERIENCE How long have you been an RN? ____ years. List present employment first: Employer ____________________________________________________ City ________________________Department ________________________________ Title _________________________________________________ From (year) ___________________________ to (year) _________________________________ Employer ____________________________________________________ City ________________________Department ________________________________ Title _________________________________________________ From (year) ___________________________ to (year) _________________________________ CNA/NNOC EXPERIENCE Start with present or most recent experience. List activities and positions held. Collective Bargaining ___________________________________________________________________________________________________________________ Organizing New Facilities ______________________________________________________________________________________________________________ State ___________________________________________________________________________________________________________________________________ National ______________________________________________________________________________________________________________________ _________ Other __________________________________________________________________________________________________________________________________ MEMBERSHIP INFORMATION I have been a member of the California Nurses Association/National Nurses Organizing Committee since ______________(year). I am willing to accept the responsibilities of this position. Date: ______________________________________Signatur e: _________________________________________________________________________________ MEMBER'S STATEMENT OF INTEREST Please write a brief statement (50 words maximum), indicating how your involvement would help increase the power of registered nurses and the California Nurses Association/National Nurses Organizing Committee to advocate for RNs, patients, and a just healthcare system. (Statements will be truncated after 50 words.) ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ Signature _________________________________________________________Name _______________________________________________________________ ——————————————————————————————————————————————————————————————————————————— FOR OFFICE USE ONLY: Member ID #: ___________________________________________________Status: _______________________________________________________________ Date: _______________________________________________________Check ed by: _______________________________________________________________ SEPTEMBER 2009 W W W. C A L N U R S E S . O R G REGISTERED NURSE 35

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