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CAREER NURSE ASSISTANTS’ NURSING ASSISTANTS’ TWENTY YEAR CLUB 2007 APPLICATION FORM Date_____________________ Facility______________________________ Contact Person______________________________________ Position___________________________________ Phone_____________________________________ Address_____________________________________________ City______________________________________ State_____________ Zip________________________________ - I grant permission to Career Nursing Assistants’ Programs, Inc. to use the name of this facility in the directory and other related publicity. YES__NO__ Facility Representative______________________________________ - The individual nursing assistant must grant permission for use of her/his name in the directory and other publicity. Please initial in the space provided below to indicate this permission. Please consider the following nursing assistants as Members of the National Twenty-Year Club 2007 NAME AS IT IS TO APPEAR ON CERTIFICATE Please type or print clearly and accurately | CNA, STNA, HHA, etc. | Total number of years of service | Permission to use name (please initial) | 1. | | | | 2. | | | | 3. | | | | 4. | | | | 5. | | | | 6. | | | | 7. | | | | 8. | | | |
Copy as needed To apply for recognition for “Ohio Most Service Year 2007” applications must be received by 5/15/07. To apply for recognition for "Most Service Years 2007," applications must be received by 8/15/07 Mail completed form to: National Network of Career Nursing Assistants 3577 Easton Road, Norton, Ohio 44203-5661 PH: (330) 825 9342 Fax: (330) 825 9378 _____________________________________________________________________________ Celebrating the 30rh annual National Nursing Assistants' Week – June 14-21, 2007 Career Nursing Assistants’ Day – June 14, 2007 Career Nurse Assistants’ Programs, Inc. is founder and sponsor of National Nursing Assistants Week, the National Network of Career Nursing Assistants, the National Twenty Year Club for Nursing Assistants, and the Savvy NA Authors Publications
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