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* 1. First Name:

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* 2. Last Name:

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* 3. Present Employer:

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* 4. Preferred Phone Number:

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* 5. PNAA Chapter Membership:

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* 6. Name of first professional reference and phone number:

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* 7. Name of second  professional reference and phone number:

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* 8. What do you hope to learn through the PNAA Leadership Fellows Program? (Not to exceed 500 words)

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* 9. Please address your future career goals and how to achieve it. (Not to exceed 500 words)

Reminder: Please provide two Letters of Recommendations (Recommendations must come from two nursing professionals who had the opportunity to witness your leadership capabilities first hand) and your current curriculum vitae. Submit your letters of recommendations and curriculum vitae to Dr. Reynaldo R. Rivera at RRR9001@nyp.org.  SUBMISSION DEADLINE is December 23, 2016, 12 midnight EST.

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