NBNA Lifetime Membership Application – Miami Chapter Black Nurses

Miami Chapter – BNA
President: Sharon Rogers
18520 NW 67th Avenue Suite # 122
Miami, FL 33015
Chapter Phone #: 305-754-2280
Chapter Email: miamibna@gmail.com

Name *

Nursing Credentials *

Email *

Experience in Nursing *

Level of Care Provided

Nurse Profile

Primary Work Setting

Nursing Specialty

Nursing Employment

Primary Role *

Sex *

Highest Degree Held

Other *

Professional Organization Membership

Other *

Age Range *

NOTE: Your responses for age and salary will remain confidential.

Annual Salary

Method of Payment *

Security Code *

Account # *

All dues expire on 12/31 of each year. Membership dues are tax-deductible. (Donations are accepted). *

Name