NYSCENA Committee Application

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NYSCENA Committee Application Deadline - January 1

* Indicates a Required Field

Name:*

Credentials:*

Date:*

Address:*

City:*

State:*

Zip Code:*

Phone:*

Email Address:* (do not use work email)

Employment Title:*

ENA Membership Number*:

Region:*

Committee applying for:*

Past experience:*

Other:

Reason for specific committee choice:*

While any member can request to join one or more committees at any time, it is preferred to send in application by January 1.
All committee members must sign a Financial Disclosure statement.