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First-Time Membership Application

This document is an initial membership application for the Organization of Nurse Executives - Connecticut (ONE-CT). It requests personal information like name, address, contact details, as well as professional information including employer, position, and demographic details such as age, education level, specialty, and area of practice. It notes the annual dues amount of $50 and provides mailing instructions to submit the completed application and payment.

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77 views

First-Time Membership Application

This document is an initial membership application for the Organization of Nurse Executives - Connecticut (ONE-CT). It requests personal information like name, address, contact details, as well as professional information including employer, position, and demographic details such as age, education level, specialty, and area of practice. It notes the annual dues amount of $50 and provides mailing instructions to submit the completed application and payment.

Uploaded by

onect
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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________________________________

Date of Application

Initial Membership Application


ONE – CT
Organization of Nurse Executives – Connecticut

PERSONAL INFORMATION:

First Name Middle Initial Last Name

Home Address – Street RN License Number

City State Zip Code Name of ONE-CT Member Who Recruited You

Home Phone Number E-Mail Address


PROFESSIONAL INFORMATION:

Organization Position or Title

Business Mailing Address – Street Business Phone Number

City State Zip Code Business Fax Number

Home Phone Number E-mail Address

Are you a member of AONE? [ ] Yes [ ] No


DEMOGRAPHICS:

AGE: [ ] 21-30 HIGHEST LEVEL OF EDUCATION: [ ] B.S.N [ ] B.S. BASIC NURSING PREPARATION: [ ] A.D.N.
[ ] 31-40 (Check all that apply) [ ] M.S.N [ ] M.B.A. [ ] B.S.N
[ ] 41-50 [ ] Ph.D. [ ] M.S. [ ] Diploma
[ ] 51-60 [ ] Ed.D. [ ] Other __________
[ ] 61-70 [ ] O.N.S. NATIONAL CERTIFICATION [ ] Yes [ ] No
[ ] Over 70 [ ] B.A.
SPECIALTY: AREA OF PRACTICE:
[ ] Administrator [ ] Mental Health [ ] Self-employed. [ ] Ambulatory Care
[ ] Critical Care [ ] Oncology [ ] Hospital [ ] HMO
[ ] Education [ ] Rehabilitation [ ] Multi-Hospital System [ ] Government Agency
[ ] Emergency [ ] Research [ ] Long-term Care [ ] Military
[ ] Gerontology [ ] Surgery [ ] College/University [ ] Maternal/Surgical
[ ] Community Health [ ] Medical/Surgical [ ] Other – Specify___________

ONE-CT Annual Dues: $50.00 (6-06)


Make checks payable to: Organization of Nurse Executives - Connecticut
Mail this application to:
Organization of Nurse Executives- Connecticut, c/o CHA, 110 Barnes Road, P.O. Box 90, Wallingford, CT 06492-0090.

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