CEN Role Delineation Study Advisory Committee Form - Board of Certification for Emergency Nursing

Name*
First Last
Email*
Number of Years in Nursing*
Number of Years Working in Specialty*
Credentials*
List all credentials other than those received from BCEN.
Current Employer
Current Position*
Current Employer Name*
Current Employer Location*
List location City and State
Practice Setting*
Main area in which you are currently employed*
Education
Degree/Diploma*
List highest degree obtained.
Area of Study*
Year Obtained*
Educational Institution*
Work History
List the 2 most recent employers
Employer Name*
Job Title*
Start Date of Employment*
Date Format: MM slash DD slash YYYY
End Date of Employment*
Date Format: MM slash DD slash YYYY
Employer Name*
Job Title*
Start Date of Employment*
Date Format: MM slash DD slash YYYY
End Date of Employment*
Date Format: MM slash DD slash YYYY
Narratives
Tell us why you would like to become a member of the CEN Role Delineation Advisory Committee:*

Current Employer