Advanced Practice Council Commitment Form - Missouri Nurses Association

APPLY NOW!

MONA ADVANCED PRACTICE COUNCIL

All participating leaders must complete this form to serve on the Advanced Practice Council within the Missouri Nurses Association (MONA). Candidates must be a current MONA member in good standing to serve (any other specific requirements will be listed in the committee description or requested upon receipt of your commitment form). Submission of this form indicates that you understand the duties and responsibilities of the council position for which you are submitting your name. If selected, you agree to fulfill the duties to the best of your ability.

BIOGRAPHICAL DATA

Position(s) Applied For: *

Vice Chair

Secretary

First Name: *

Last Name: *

Credentials: *

Street: *

City *

State: *

Zip: *

Daytime Phone: *

Mobile Phone: *

Email *

Position Statement: *

OPTIONAL INFORMATION

Primary Area of Expertise/Specialty:

Employer:

Employer Street:

Employer City:

Employer State:

Employer Zip:

Education:

Present Organizational Leadership Positions:

Past Organizational Leadership Positions:

Organizational Nursing and Civic Involvement:

I understand the duties and responsibilities of the office for which I am submitting my name as outlined in the APC guidelines. If elected, I agree to fulfill the duties of the office to the best of my ability. *

By checking this box and submitting this form, I am providing my electronic signature to confirm that the information provided above is accurate.

Captcha *

reCAPTCHA is required.