Interested individuals should submit their application, curriculum vitae, and letter of recommendation on or before March 31, 2018.

Transcription

1 This is a fillable frm. Please dwnlad this pdf, cmplete the frm electrnically, save it t yur cmputer, and the dcument t nminatins@nbcrna.cm. EMERGING LEADER FELLOWSHIP The NBCRNA is seeking applicants fr the Bard f Directrs Emerging Leader Fellwship. Applicants will be nurse anesthetists wh have been initially certified in the past 2 5 years. The Emerging Leader Fellwship is ne-year pprtunity fr newly certified nurse anesthetists identified as future leaders in the prfessin. Interested individuals shuld submit their applicatin, curriculum vitae, and letter f recmmendatin n r befre March 31, Date f Applicatin: Yur Infrmatin First Name: MI: Last Name: AANA Membership Yes N I am currently an active member f the AANA. Yes N If selected fr the Emerging Leader Fellwship, I agree t becme an active member f the AANA, if I am nt currently a member. Certificatin The fellwship is intended fr certified registered nurse anesthetists initially certified in the past 2 t 5 years. In what year were yu initially certified as a nurse anesthetist? Cntact Infrmatin Hme Street Address Hme Phne * City State Zip Cell Phne Fax Business Current Emplyer Business Street Address Business Phne Jb Title: Emplyer City State *All applicants must have an address and the ability t access it daily. Zip Business Fax

2 Questinnaire Why are yu interested in the Emerging Leader Fellwship? (up t 250 wrds) What are yur leadership gals in the shrt term (ver the next 5 years) and lng term? (up t 250 wrds) Describe yur current emplyment, including majr clinical, teaching r practice area; field/place f emplyment; and respnsibilities. (up t 250 wrds)

3 NBCRNA BOARD OF DIRECTORS Educatin and Credentials List yur educatinal histry. (Please begin with highest degree/credential earned.) Degree/Diplma Area f Study Year Obtained Educatinal Institutin Wrk Histry List yur wrk practice/emplyment histry. (Please begin with the mst recent psitin.) Emplyer Respnsibilities Jb Title Emplyer Respnsibilities Jb Title Emplyer Respnsibilities Jb Title Have yu ever been asked t leave r resign frm a prfessinal nursing psitin, lst yur privileges, r had disciplinary actin taken against yur license? yes n If yes, please explain.

4 NBCRNA BOARD OF DIRECTORS Prfessinal Memberships, Affiliatins, Elected Psitins, and Leadership Experience List elected r appinted psitins and/r invlvement n bards r cmmittees at the cmmunity, state r natinal level, r at educatinal institutins. Attestatins My service n the Bard wuld nt represent a persnal r prfessinal cnflict f interest. I can make a substantial time cmmitment t be an active cntributr t the Bard. I am available t attend the Bard meetings n August 24-25, 2018; January 25-26, 2019; April 26-27, 2019 and August 23-24, I can attend a mandatry tw-day Bard rientatin in Chicag, July 30-31, I am nt a directr r emplyee f any rganizatin that may have a direct r indirect cnflict with the NBCRNA. If selected fr the Emerging Leader Fellwship, I agree t attend all meetings and cmplete all assignments as required by the NBCRNA; prduce a reprt fr the bard reflecting the fellwship experience; and serve as a mentr t ther NBCRNA fellws as requested by the NBCRNA President. I understand in rder t be cnsidered, the applicatin frm, curriculum vitae, and ne cnfidential letter f recmmendatin must be submitted by the deadline date f March 31, Signature: Date: Nte: By printing yur name abve, yu will be cnsidered t have signed this frm.

5 Letter f Recmmendatin One cnfidential letter f recmmendatin frm smene wh wuld supprt yur selectin must be received n r befre March 31, 2018 via r pst t: NBCRNA Nminatins Cmmittee 8725 W. Higgins Rad Suite 525 Chicag, IL nminatins@nbcrna.cm Wh will be prviding yur letter f recmmendatin? Name Phne Business/Institutin Address: Crrespndence Interested individuals shuld submit their applicatin, curriculum vitae, and ne letter f recmmendatin n r befre March 31, 2018 t nminatins@nbcrna.cm. Questins shuld be directed t: nminatins@nbcrna.cm 2018 Timeline March 31 March/April April 26 May June 1 Applicatins due t the NBCRNA Leadership Develpment and Nminatins Cmmittee review applicatins Phne interviews fr selected applicants Leadership Develpment and Nminatins Cmmittee reviews results and ntifies candidates Psting f results