ENA Emergency Nurses Association - Emergency Nurses 411 Form

Emergency Nurses 411
Application Form

Name: Date:

ENA Member #: Referred By:

Home Address:

City: State: Zip Code:

Home Phone: Work Phone:

Fax Number: Email Address::

Prior political advocacy experience is not necessary to join ENA's Emergency Nurses 411 Program although it is helpful for us to know if you have any experience in local, state or federal legislative advocacy or politics. Please check below if you have experience in any of the following areas:

Federal key contact experience	State key contact experience
Attended NIWI (Nurse in Washington Internship)	Served as a State Council/Chapter Government Affairs or Injury Prevention Chair
Other political training:
Public office experience:
Other:
Please list any political contacts/relationships you have with your federal legislators.
Why do you want to be involved with EN411?

QUESTIONS? enagov@aol.com or Call Kathi Ream, ENA's Washington Representative at 703-241-3947