2017 Georgia Nurses Association Yearbook

12. Involvement in community, state, or national health care concerns:
(Provide specific information)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
13. Certification
I understand that GNA policy requires that no officer or director of the Board or appointed Committee
Member shall serve concurrently as an officer or director of a board of another association or body if such
participation might result in conflict of interest to GNA or the individual as determined by the Board. I also
understand that I may be requested to provide the GNA Board of Directors with additional information.
I authorize GNA to include my name, home address, cell phone, and e-mail address on rosters if elected/
appointed.
I certify that my signature below indicates that, if elected or appointed, I promise to fulfill all accountabilities
and assignments as called for by Bylaws, Policies, and Strategic Plan of the Association.
Further, I certify that my signature below indicates my consent to serve, if elected or appointed, and that, in
accordance with the above referenced GNA policy, I do not hold membership on a board of directors or other
governing body of any other organization which could result in a conflict of interest.
I certify that the information on this form is true and accurate to the best of my knowledge.
Nominee’s Signature:_________________________________ Date:_________________
Please mail, fax, email or hand-deliver this form to: Georgia Nurses Association
Looking Back...Moving Forward “Taking Care of the WHOLE Nurse”
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