The World Federation of Neuroscience Nurses

WFNN Exhange Program Application Form

Biographical Information :

First Name:	Last Name:

Mailing Address:

City:	State:	Zip:

Country:	Phone Number: (Including country code)	Email Address:


Professional Information:

WFNN Member Country:	WFNN Member Organization:

Nursing Certification or License #: (Please provide copy of your RN certificate, accompanied by an English translation (as necessary) of the copied document. A colleague or supervisor should sign the translation.)
Current Place of Work:

5. List involvement in any WFNN or general neuroscience nursing committees, work groups, volunteer contributions.
Within WFNN:	Member Association:

Other, Including Workplace:

6. Are you a member or officer of any committees within your WFNN member association? If so, please state.

Describe, in English, in 350 words or less, your reasons for applying for the WFNN Exchange Grant. Please include the following: 1. Objectives 2. Host institution, hospital, person and reason for this selection 3. Planned activites during exchange 4. Desired outcome(s) from the proposed exchange.