07.02.2013 Views

THE GROUP NEWSLETTER - SWOG

THE GROUP NEWSLETTER - SWOG

THE GROUP NEWSLETTER - SWOG

SHOW MORE
SHOW LESS

Create successful ePaper yourself

Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.

Page 18<br />

SOUTHWEST ONCOLOGY <strong>GROUP</strong><br />

Nurse Oncologist Committee<br />

MEMBERSHIP APPLICATION F ORM<br />

DECEMBER 2003<br />

<strong>THE</strong> <strong>GROUP</strong> N EWSLETTER<br />

Date Submitted: ___________________________ Date Received: ___________________________<br />

Please note it is highly recommended that you attend at least one out of every four meetings to become a member and<br />

maintain membership status. If you have questions regarding this application, please call Patra K. Grevstad, RN, MN,<br />

at (206) 386-2442 or email at: patra.grevstad@swedish.org.<br />

Name and Credentials: ___________________________________________________________<br />

Current Position: ___________________________________________________________<br />

Social Security Number: __________________________ Specialty:_________________________<br />

Business Address: ____________________________________________________________<br />

____________________________________________________________<br />

____________________________________________________________<br />

Phone:___________________________ Fax: ___________________________<br />

E-Mail Address: ____________________________________________________________<br />

Principal Investigator: ____________________________________________________________<br />

Group Status __ Member __ CCOP __ Affiliate __ UCOP<br />

__Other: _____________________________<br />

WOULD YOU BE INTERESTED IN HAVING A MENTOR? _____ YES _____NO<br />

If you are interested in becoming a member of a specific Subcommittee, please check the appropriate box(es) below;<br />

information will be sent to you.<br />

__ Disease and Discipline __ Education __ Research __ Program __ Membership<br />

Required Information (must accompany application): Curriculum Vitae, Resume, or Biographical Sketch<br />

I have reviewed the above application for membership in the nurse oncologist committee and recommend approval for the<br />

above applicant. My signature below affirms this recommendation plus my commitment to providing opportunities for<br />

attendance to <strong>SWOG</strong> meetings in order to maintain membership status.<br />

______________________________________________________________<br />

Principal Investigator<br />

PLEASE MAIL COMPLETED FORM AND REQUIRED INFORMATION TO :<br />

Patra K. Grevstad, RN, MN<br />

Membership Chair, <strong>SWOG</strong> Nurse Oncologist Committee<br />

Swedish Cancer Institute<br />

1221 Madison, Suite #400<br />

Seattle, WA 98104<br />

Rev 04/03

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!