Association of Deans of Philippine Colleges of Nursing, Inc. (ADPCN, Inc.
)
137 Mathimik St., UP Village, Diliman, Quezon City
Telefax No. : (02) 921-74-66
E-mail add : [email protected]
Website : www.adpcn.org
Application for Regular Membership : ADPCN Membership I.D. No.:
Academic Year 20___ to 20___ Region _______
/ Check the following as:
New (Php 2,000)
Renewal (Php 1,000) 1x1
Associate (Past Dean for 3 years) (Php 1,000) Picture
[ ] Membership ID Card (150.00)
[ ] Membership ID Card to be sent via Courier (150.00)
PERSONAL DATA
Name : ________________________________________________________________
Surname First Name Middle Name
Date of Birth: ___________________________ Sex: ________ Religion: ______________
Home Address: ______________________________________________________________
Telephone: _____________ Cell phone ___________ Fax ___________Email ___________
Name of School: _____________________________________________________________
Address: ___________________________________________________________________
Telephone: ______________________ Fax ______________ Email ____________________
Position Title: _________________________Exact Date of Appointment ______________
Name of School President: ____________________________________________________
Academic Record
Educational School Attended Dates of Degree Received
Level Attendance
Collegiate
Masters
Doctorate
Others
Work Record (start with position held before Deanship)
Position Institution / Employer Year Inclusive
Written works / Publications / Research Study
Title Date Where Published
NOTE : Please see at the back of this page the requirements to be submitted. Thank you.
ACTION TAKEN
_____ Approved _____ For Payment _____ For Issuance of ID ______________________________
_____ Disapproved, due to ______________________________
_____ Deferred pending compliance ______________________ Signature over Printed Name
______________________________________________________ PRC License No. __________________
Approved By:
Expiry Date: ______________________
_____________________________________________________
Membership Chair / Member’s Signature over Printed Name / Date
Membership Form
Revised (September 2014)
Membership Committee 2014
REQUIREMENTS TO BE SUBMITTED:
New Membership :
1. ADPCN Membership Personal Data Form
2. Original copy of notarized appointment as the Dean of the College of Nursing
(NOT a certificate as Dean, nor as an Officer-In-Charge (OIC)
3. Original copy of notarized Employment Contract
4. Photocopy of TOR, Diploma (BSN, MAN/MSN or PhD/Ed.D if applicable)
5. 1 pc. 1x1 and 1pc. 2x2 ID picture in white background
6. CHED Recognition Certificate of the College of Nursing
7. Photocopy of updated PRC License
Renewal Membership :
1. ADPCN Membership Personal Data Form
2. Original copy of notarized appointment as the Dean of the College of Nursing (NOT a certificate as
Dean, nor as an “OIC”)
3. Original copy of notarized Employment Contract
4. 1 pc. 1x1 and 1pc. 2x2 ID picture in white background
5. Photocopy of updated PRC License
Associate Membership :
1. A FORMER DEAN who had been a member of ADPCN for at least three (3) years
2. ADPCN Membership Personal Data Form
3. Letter of interest in continuing with his / her membership to ADPCN address to the ADPCN President
and ADPCN Membership Committee Chairperson.
4. Updated Curriculum Vitae with picture.
5. 1 pc. 1x1 and 1pc. 2x2 ID picture in white background
6. Photocopy of updated PRC License.
7. The old ADPCN card will be surrendered to the ADPCN National Office.
NOTE: For the New, Renewal and Associate Membership please wait for the approval of your application by
the Membership Committee before you pay the membership fee. The review of your application will be two
(2) weeks.
Membership fee shall be paid annually and is valid for one (1) fiscal year from June 1 to May 31. Members
who have not paid his / her annual membership dues shall have to update his / her payment before renewal.
Per CMO#14 S. 2009 Article VI Section 10.i :
Upon appointment, he/she must be an active member of good standing of the
Association of Deans of Philippine Colleges of Nursing (ADPCN)
Payment Details:
Name of Bank and Branch : Philippine National Bank (PNB) Quezon City Circle Branch
Account Name : Association of Deans of Philippine Colleges of Nursing, Inc.
Account No. : 108370007367
Please fax or e-mail to ADPCN the copy of your deposit slip.
Telefax No. : (02) 921-74-66
E-mail add : [email protected]
or you can settle your payment to ADPCN National Office at
137 Matahimik St., UP Village, Diliman, Quezon City
Membership Form
Revised (September 2014)
Membership Committee 2014
