Austin Area AORN

Workshop Application

Name:  _______________________________________________

Home Address: ________________________________________

        __________________________________________________

        __________________________________________________

Home Phone:___________________________________________

Work Phone:___________________________________________

Title of Workshop:_______________________________________
Location of Workshop
            City:_______________________________________
            Place:______________________________________
            Date of Workshop:_________________________________

            ______I have attended at least seven (7) chapter meetings in the past twelve (12) months.
            ______I understand that I must submit a copy of the CEU certificate within 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 Signature:____________________________________
Date:________________________________________________