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Willingness-to-Serve Form
 
PLEASE NOTE: You must send in your CV along with your application. Please email it directly to wts@cc-institute.org. If you wish to fill out a paper WTS application, you can download it and email it back to us at the same email.

Personal Information
    First Name    
    Last Name    
  Street Address 1    
  Street Address 2    
  City    
  State/Province     (if not U.S. state)
  Zip/Postal Code    
  Country       (if not U.S.)
  Home Phone    
  Home Email    

Professional Information
  Company    
  Street Address 1    
  Street Address 2    
  City    
  State/Province     (if not U.S. state)
  Zip/Postal Code    
  Country       (if not U.S.)
  Work Phone    
  Work Email    
  Preferred Contact
Address		    

Education
  Begin with highest degree earned and include degree/diploma, area of study, year obtained and educational institution.
 
  Degree Area of Study Year Institution
Degree 1
Degree 2
Degree 3
         

Certifications
  Include organization, type and expiration date.
 
  Cert. Type Organization Expiration Date (e.g. "1/1/2009")
Certification 1
Certification 2
Certification 3
       

Demographic Information
  Answers to the following questions will be used only for demographic purposes and are voluntary.
  Sex    
  Race/Ethnic Group    
 

Background Information
  Year(s) Certified as CNOR
(numbers only, please) 		   
  Year(s) Certified as CRNFA
(numbers only, please)		    
  AORN Member?    
  Years in Nursing    
  Years in Surgical
Nursing		    
  Current Position(s)
(check all that apply)		     Administration
Education
Staff Nurse
RN First Assistant
Consultant
Industry

(if other)

Positions of Interest/Past Experience
The following committees will require volunteers in the upcoming year (beginning Fall 2008). Rank your top five choices (1-5) in order of preference. Please also indicate your past experience by filling in the number of times you have been on each committee and the number of years spent. Please indicate all terms in the Years field. Example:1988 , 1989, 1994, 2007 or 1994-1996
 
Rank (1-5)    Position # Times Year(s)
  CNOR Item Writing Committee
  CRNFA Item Writing Committee
  CNOR Item Review Committee
  CRNFA Item Review Committee
  CCI Board Member

Summary Statement
  In 100 words or less, please describe why you'd like to serve on a CCI committee or on the Board of Directors, and how you would contribute to CCI's mission to ensure innovative methods are in place for the continued competency assessment of healthcare providers.
 

Board of Directors Statement (Board Applicants Only)
  In 100 words or less, please tell us how your skills and experience match our leadership characteristics.
 

CV Submission Required
You must send in your CV along with your application. We will NOT consider your application until we are in receipt of your CV.
  I have sent my CV via email directly to CCI at wts@cc-institute.org.

Statement of Understanding
I understand the requirements of the position I am seeking as outlined in the willingness-to-serve form. I further understand the time commitment necessary to serve as a volunteer with CCI.
  I have read and agree with the statement of understanding.
 
 

 

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