Clone of UCLA Health New Nursing Certification- Jacket Order Form 2015

New Nursing Certification - Jacket Order Form 2015
A nurse is eligible for a certification jacket upon receiving his/her first nationally recognized certification. To see if your new certification qualifies you for a jacket, please check the full list of Nursing Certifications on the UCLA Health Nursing website. (http://www.mednet.ucla.edu/nursing/PDF/ANCCApprovalList.pdf)

Please update this information in the UCLA Health Magnet Demographics Database at http://hrsurvey.mednet.ucla.edu
Before nursing certification jackets can be distributed, the following criteria must be met (check all that apply):
Please confirm the following:*

I have updated my demographic information in the UCLA Health Magnet Demographics Database at http://hrsurvey.mednet.ucla.eduI have received my first nationally recognized certification between 4/1/2014-4/1/2015I confirm that I have not previously received a nursing certification jacket from UCLA Health
Please complete the following information to receive your New Nursing Degree shirt:
Your hospital:*
Your Unit:*
Manager Name:*
Your UCLA Employee ID #:*
Nat'l Nursing/Health Certifying Body:*
Certification/ Credential title:*
Men's Microfleece Jacket Sizes:

SmallMediumLargeXLarge2XL3XL
Women's Microfleece Jacket Sizes:

XSmallSmallMediumLargeXLarge2XL3XL
*Jackets will be delivered to your residence via UPS Ground*
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Your RESIDENTIAL Address (include apartment #, if applicable):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Please submit any questions to Jennifer Zanotti at jzanotti@mednet.ucla.edu or Charlene Collazzi at ccollazzi@mednet.ucla.edu
Thank you & Congratulations on your professional achievements!
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New Nursing Certification - Jacket Order Form 2015