Delegate Willingness to Serve Form

Delegate Washington DC, 2006
Due by October 1, 2005 .

I, ________________________ , have read and understand the following eligibility requirements, delegate responsibilities, and chapter policies for serving as a chapter delegate as indicated by my checking each point. As signified by my signature at the bottom of this page I agree to meet my responsibilities and follow these rules:

Eligibility Requirements: (If you do not meet the requirements please comment on why you do not and why you think you would still serve the chapter well as a delegate.)
o 1. I have been a member of national AORN for at least the preceding 2 years and a member of the Southern Arizona chapter for at least 1 year.
o 2. I have attended at least 3 Southern Arizona chapter business meetings in the preceding 12 months.
o 3. I have served on a Southern Arizona chapter committee.
o 4. I did not serve as a delegate for the Southern Arizona chapter at the 2005 Congress. If you did serve as a delegate in 2005, you understand that you cannot serve as a delegate this year unless a) you are chapter President, b) you are a candidate on the national ballot, c) there are insufficient numbers of qualified applicants.

Delegate Responsibilities:
o 1. Submit the willingness to serve form within the time guidelines.
o 2. Adhere to National AORN directives regarding delegate responsibilities.
o 3. Attend ALL business sessions, special delegate activities, and other meetings as required by the President or delegate chairperson at the Annual AORN Congress.
o 4. Seek information on all issues and candidates and solicit member input on voting preferences.
o 5. Vote as a delegation and as recommended by chapter membership if directed to do so by the President.
o 6. Attend educational and scientific meetings and exhibits.
o 7. Present an oral report to the Southern Arizona chapter membership if requested to do so.

Chapter Policy:
o 1. In the event I cannot attend Congress I understand that I must contact the Southern Arizona chapter President immediately so that an alternate can be named.
o 2. I also understand that if I cannot attend Congress or do not fulfill my obligations as delegate at Congress I MUST REIMBURSE THE FULL AMOUNT RECEIVED FROM THE SOUTHERN ARIZONA CHAPTER OF AORN.
o 3. If I receive full Congress funding from another source, I understand that I will not receive (or will return) local chapter delegate funding so as not to constitute a moneymaking endeavor.

If elected I will serve the chapter to the best of my ability. I believe the organization would benefit from my serving as delegate because: (this will be published as written with the ballot as your candidate statement.)

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My qualifications include: (Check all that apply)
o Currently a member of the Southern Arizona chapter of AORN (for as least 1 year
o Attended at least 3 business meetings last year
o Committee Participation
o Previous Congress Delegate Year(s) __________
o CNOR/RNFA

Other qualifications you would like to add if not addressed in your delegate statement above:


Signature: ____________________________________ Date: __________
Home # ________________ Daytime #______________

Please submit this form to Cathleen Benbow, Chair-Nominating Committee