Intent to Level in Heart and Vascular Clinical Career Program
Letter of Intent to Level
(Part One)
Date: _______________
I, _________________________________, am applying for the Heart & Vascular
Clinical Career Program. I am aware of and in agreement with the following terms:
1. I am entering this program by my own choice and understand that I am solely
responsible for meeting all requirements.
2. I am responsible for obtaining documentation and validation of signatures as
required, as well as maintaining any other information needed.
3. I understand that, in order to advance or maintain my level in the Heart &
Vascular Clinical Career Program; I must meet the annual requirements as
outlined in this program booklet.
4. I understand I may level only once in a twelve (12) month period.
5. The Heart & Vascular Clinical Career Board will review my application and
recommend my promotion within the Heart & Vascular Clinical Career Program.
Signature: ______________________________, ___________________ Title
(Applicant)
Name (Print): ___________________________ Date: ________________
Unit: ______ Director/ Manager’s Signature ___________________________
Date: ________________
(By your signature, you confirm that the candidate has achieved “meets or exceeds
expectations” on the last annual evaluation and has not received as disciplinary action
>level 2. In the absence of a Director/ Manager, the AVP or VP for that area must sign.)
Intent to Level in Phoebe’s Heart and Vascular Clinical Career Program
Letter of Intent to Level
(Part Two)
Name/ Title: _______________________________________________________
Work Area: _______________________________________________________
Level I am Applying for: ____________________________________________
Highest Nursing Degree: ____________________________________________
Highest Non-Nursing Degree: ________________________________________
List of Specialty Certifications: _______________________________________
Years as a Nurse/ Technologist: ___________________
Years as a Nurse/ Technologist at PPMH Heart & Vascular Center: ________
Contact Information:
Work / Extension: __________________/_______________
Home: __________________________________
E-mail: __________________________________________
Preferred Method of Contact: ___________________________