CAREER NURSE ASSISTANTS� NURSING ASSISTANTS� TWENTY YEAR CLUB 2001 APPLICATION FORM

Date:
Facility:
Contact Person:
Postion:
Address:
City:
State: Zip:
Phone:
Fax:
Email:
Our facility, group or organization is a member of the NNCNA.
No Yes Member #
I grant permission to Career Nursing Assistants' Programs, Inc. to use the name of this facility in the directory and other related publicity.
No Yes Facility Rep.
The individual nursing assistant must grant permission for use of her/his name in the directory and other publicity. Please fill in the space provided below to indicate this permission.
Please consider the following nursing assistants as Members of the National Twenty Year Club 2001:
  Name as it is to appear on certificate Number of years of service CNA, STNA, HHA, etc. Perm-ission to use Name
1.
2.
3.
4.
5.
6.
7.

•Individual nursing assistant applicant = no charge

Member facilities, groups, and organizations
•First 10 applicants = no charge
•Additional applicants = $10 ea.

Non-member facilities, groups, and organizations
•Each applicant = $10 ea.

Send invoice to: (Billing address if different than above)
Attention:
Address:
City:
State: Zip:
Phone:
Fax:
Email:
Additional information, verification of service, and billing information may be requested from applicants.
 
For more information contact:
Genevieve Gipson RN MEd RNC, Director,
National Network of Career Nursing Assistants,
3577 Easton Road, Norton, Ohio 44203,
(330) 825 9342. (330) 825 9378-fax.
[email protected] - email

Send Your Comments & Feedback to:
[email protected]