Austin Area AORN

WORKSHOP APPLICATION

Name ________________________________________________________________

Home Address _________________________________________________________

                                   Street                                                  City               State    Zip

 Home Phone _________________________ Work Phone ______________________

Title of Workshop _______________________________________________________    

Location of Workshop ____________________________________________________

                                                  City                                           Place

Date of Workshop _______________________________________________________

            _______ I have attended at least 7 chapter meetings of the past 12 months. 

            _______ I understand that I must submit a copy of the CEU certificate withing 2 weeks after the workshop. 

            _______ If I receive the money before the workshop and I do not attend the workshop, I will refund the money, within one (1) week of the workshop.

_______________________________                                          ___________________

           Applicant’s Signature                                                                         Date