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2022 NBNA Lifetime Membership Application
2022 NBNA Membership Application
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2022 NBNA Lifetime Membership Application
Miami BNA
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2022 NBNA Lifetime Membership Application
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Name
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Nursing Credentials
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Address
*
Address Line 1
Address Line 2
City
Alabama
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Delaware
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Zip Code
Phone
*
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*
Experience in Nursing
*
Less than 2 Years
2-5 Years
6 – 10 years
11 – 15 years
16 – 20 years
More than 20 years
Level of Care Provided
*
In-patient
Out-patient Ambulatory
Public Health Department
Nurse Profile
*
ANA Certified
Generalist (RN, C)
Specialist (RN, CS)
Prescriptive Authority
Primary Work Setting
*
Private Non-Profit Hospital
Public/Federal Hospital
Private, Investor-Owned Hospital
School/College of Nursing
Independent/Private Practice
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Behavioral Care Company/HMO
Community Agency
Research
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Nursing Specialty
*
Nursing Employment
*
Full Time
Part-Time
Retired
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Primary Role
*
Admin/Dir/VP of Nursing
Nurse Manager
Assistant Nurse Manager
Adv Practice Nurse
Researcher
Consultant
Educator
Case Manager
RN
LPN/LVN
Professor
Associate Professor
Assistant Professor
Staff
Sex
*
Female
Male
Highest Degree Held
*
Associate Degree
Second Choice
Baccalaureate in Nursing
Another Baccalaureate
Master’s in Nursing
Another Master’s
Doctorate in Nursing
Other
Other
*
Professional Organization Membership
*
American Nurses Association
American Association of Critical
Care Nurses
National League for Nursing
Chi Eta Phi
American Public Health Association
American Academy of Nursing
Other
Other
*
Age Range
*
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65 plus
NOTE: Your responses for age and salary will remain confidential.
Annual Salary
*
$20,000 – $29,999
$30,000 – $39,999
$40,000 – $49,999
$50,000 – $59,999
$60,000 – $69,999
$70,000 – $79,999
$80,000 – PLUS
Method of Payment
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Check
Money order
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Expiration Date
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Security Code
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Account #
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Address associated with payment method
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Arizona
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Delaware
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Florida
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Idaho
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Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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South Carolina
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Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Full Lifetime dues is $2,000.00 plus Local dues for the chapter you are affiliated with or joining. You can also pay in 4 installments of $500.00 plus local dues with the first installment. You have one year cycle to pay from your starting date. Final installment is required May 15th of each year if you would like your name to be printed in the conference program book.
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2022 NBNA Lifetime Membership Application
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