THE GROUP NEWSLETTER - SWOG
THE GROUP NEWSLETTER - SWOG
THE GROUP NEWSLETTER - SWOG
- TAGS
- newsletter
- swog
- swog.org
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