National Nurses United

Consent-to-Serve Form Member Information This form must be postmarked on or before Dec. 1, 2005 and mailed to CNA Administrative Office, Attention: Appointments, 2000 Franklin St., Oakland, CA 94612. Please complete all sections of this form. Faxes will not be accepted, as an original signature is required. Terms are for the 2005-2007 biennium. CANDIDATE FOR ❏ CNA Political Action Committee (PAC) ❏ Legislative-Regulatory Committee ❏ Bylaws Committee Please check contact preferences _____ Mail _____ Phone _____ E-mail Name (please print) –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Region ––––––––––––––––––––––––—— Address (Home) ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––—— City ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Zip –––––––––––––––––––——— Phone (Home) ( ––––– ) –––––––––––––– (Cell) ( ––––– ) –––––––––––––– Email –––––––––––––––––––––––––––––––––––––––––––— Employer ––––––––––––––––––––––––––––––––––––––––––––––––––– City –––––––––––––––––––––––––––––––––––––––––––––––––– Department ––––––––––––––––––––––––––––––––––––––––––––––––– Shift ––––––––––––––––––––––––––––––––––––––––––––––––––— RN EXPERIENCE How long have you been an RN? ––––––––––––– years. (List present employment first) 1. Employer –––––––––––––––––––––––––––––––––––—–—–—–—–– City ––––––––––––––––––––––––––––––– Department –––––––––––––––––––—– Title ––––––––––––––––––––––––––––––—–—–—–—–—–—–—–—–—–—–—–—––––—–—–—–—–—– Time:From (Year) –––––––––––––––– To (Year) –––––––––––––––– 2. Employer ––––––––––––––––––––––––––––––––––––– City ––––––––––––––––––––––––––––––– Department –––––––––––––––––––—– Title ––––––––––––––––––––––––––––––—–—–—–—–—–—–—–—–—–—–—–—––––—–—–—–—–—– Time:From (Year) –––––––––––––––– To (Year) –––––––––––––––– CNA EXPERIENCE Starting 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 since ––––––––––––––––––––– (year). I am willing to accept the responsibilities of this position. Date: ––––––––––––––––––––––––––––––––––––––– Signature: ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 22 O C T O B E R 2 0 0 5 C A L I F O R N I A N U R S E CNA members in good standing are hereby notified of 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, pres- ent employment, and position. Such forms for consents-to-serve are available from and should be mailed to the CNA Administrative Office, Attention: Appointments, 2000 Franklin St., Oakland, CA 94612. They must be returned by Dec. 1, 2005. 2005 CNA Committee Positions

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