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* 1. Full Name:

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* 2. Phone Number:

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* 3. Email Address:

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* 4. Institution:

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* 5. Job Title:

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* 6. Are you a current ITNS member?

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* 7. How long have you been employed in the area of Transplant Nursing?

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* 8. How have you contributed to the field and the mission of ITNS? “…promotion of excellence in transplant clinical nursing through the provision of educational and professional growth opportunities, interdisciplinary networking, collaborative activities, and transplant nursing research."

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* 9. Are you currently or have you contributed to ITNS in a volunteer role? If yes, please describe your experience.

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* 10. Provide an example of a time when your direct patient intervention or care contributed to your professional growth or collaborative approach to transplant nursing.

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* 11. Have you participated in the development of patient or staff education materials? If yes, please describe your involvement.

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* 12. What are your goals looking ahead? How do you intend to make an impact in the field of transplantation and what education would you need to support that effort?

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* 13. Letter of Recommendation:

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