National Nurses United

Election 1/9/07 1:05 PM Page 18 Consent-to-Serve and This form must be postmarked on or before February 15, 2007 and mailed to CNA/NNOC Headquarters Office, 2000 Franklin Street, Oakland, CA 94612; Attn: 2007 Elections. Please complete all sections of this form. Faxed or e-mailed forms will not be accepted, as an original signa ture is required. Terms of office are for the 2007/2009 biennium. CANDIDATE FOR (Check all that apply): ❏ House of Delegates: Region _____ ❏ Council of Presidents – Slate of Four List other individuals on slate below. Each slate must have four members to be eligible for the ballot. Each member of each slate must complete and sign their own consent-to-serve form in order for the slate to be valid. An individual can only run on one slate. 1. ________________________________ 2. _________________________________ 3. ___________________________________ ❏ Treasurer ❏ Secretary ❏ Board of Directors: Regional sub-grouping _____ ❏ Ballot Committee ❏ Joint Nursing Practice Commission (Check one) At-large: NP/CNS ____ At-large: Educator ____ Region (specify) ____ Please check contact preferences ❏ Mail ❏ Phone ❏ 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 _________________________________________________________________________________________________________________________ 18 REGISTERED NURSE W W W. C A L N U R S E S . O R G DECEMBER 2006

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