Title: Willingness to Volunteer
Author: Thomas J. Macheski
Last saved by: Valued Gateway Client

The Florida Council of Operating Room Nurses

Willingness to Volunteer

For the Year:                                   

I would like to volunteer my services as possible Chair or Member of the following Committee(s). I have requested, received, and reviewed copies of the FCORN ByLaws and Policy. I understand the duties and responsibilities of the office for which I am submitting my name as a candidate and will be able to fulfill same.

Name: 	Title 
Home Address: 
	City: 	, FL Zip Code: 
Home Phone: 	email 
Workplace: 	Position 
Business Address: 
	City: 	, FL Zip Code: 
Work Phone: 	email 

Chapter
Name: 	Number: 
Membership Number: 
 
Please circle your selection(s):

ByLaws and Policy:
Legislative:
Ways and Means:
Newsletter:
RNFA:

chair member
chair member
chair member
chair member
chair member

Research:
Membership:
Scholarship:
Education:
Informatics:

chair member
chair member
chair member
chair member
chair member

I would like to have a special committee formed to study and respond the following issue(s) confronting perioperative nursing in Florida:

Signed: 
Date: