Louisiana Emergency Nurses Association
2009 Delegate Selection Application Form
Copies of current ENA membership and proof of successful completion of any applicable certification must be attached with completed application form. Applicants should send their completed form to the Membership Chair by July 15, 2009.
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Applicant Information ( Please Print )
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Applicant Name:
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Home Address:
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City:
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State:
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Zip Code:
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Telephone:
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Home:
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CELL PHONE:
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E-Mail:
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ENA Membership #:
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Expiration Date:
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Prior General Assembly Delegate?
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YES: NO:
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Section 1
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Elected Positions held January 1, 2009 – May 31, 2009
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National
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State
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Local
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Office
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Value
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Points
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President
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8
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President-Elect
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8
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Secretary
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8
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Treasurer
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8
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Director
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8
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Immediate Past President
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8
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TOTAL SECTION POINTS
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Section 2
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Committee Positions held during January 1, 2009 – May 31, 2009
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National/State/Local
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Name of Committee/Work Group
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Value (circle)
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Points
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National
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Chair-8 / Member-6
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State
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Chair-6 / Member-4
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State
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Chair-6 / Member-4
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Special Committee
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Chair-6/Member-4
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Local
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Chair-6 / Member-4
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Local
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Chair-6 / Member-4
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TOTAL SECTION POINTS
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Section 3
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Special Interest Group Meeting Attendance from June 1, 2008 – May 31, 2009
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Local
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Monthly Meetings – Jun Jul Aug Sept
Oct Nov Dec Jan Feb Mar Apr May
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2 each circled meeting
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TOTAL SECTION POINTS
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Section 4
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National/State Meeting Attendance from June 1, 2008 – May 31, 2009
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Level
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Meeting
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Value
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Points
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National
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General Assembly Delegate / Alternate
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6
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National
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Scientific Assembly
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6
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National
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Leadership Symposium
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6
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State
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Quarterly (July 2008)
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LENA Board– 4
Attendee – 2
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State
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Quarterly (October 2008)
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LENA Board– 4
Attendee – 2
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State
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Quarterly (January 2009)
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LENA Board– 4
Attendee – 2
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State
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Quarterly (April 2009)
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LENA Board– 4
Attendee – 2
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TOTAL SECTION POINTS
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Section 5
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CERTIFICATIONS
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Credential/Certification
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Note
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Value
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Points
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ENPC
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You MUST attach a copy of your card
No Copy – No Points
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Provider – 2 OR Instructor – 4 OR
Chapter Sponsored Course Coordinator – 6
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TNCC
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Provider – 2 OR Instructor – 4 OR Chapter Sponsored Course Coordinator – 6
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CEN
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6
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CFRN
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6
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CTRN
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6
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CPEN
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6
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CEN Course Director
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4
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FAEN
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8
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TOTAL SECTION POINTS
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Section 6
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OTHER ACTIVITIES FROM JUNE 1, 2008 – MAY 31, 2009
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Credential/Certification
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Description
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Value
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Points
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Approved Special Project
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N-6 S-4 L-2
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Published Articles (Submit Copy)
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N-6 S-4 L-2
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ENA Speaker (Provide Program Copy)
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N-6 S-4 L-2
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TOTAL SECTION POINTS
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Total Cumulative Points:
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Date:
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Applicant Signature:
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Did you remember to attach copies of current ENA membership and certification cards?
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Date:
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Telephone:
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Dawn McKeown, P.O. Box 5067, Bossier City, LA. 71171-5067
