NBNA 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

Membership Type *

New
Renewing
Lifetime Member

Year you became a lifetime Member *

Name *

Credentials *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Nursing Liscense #

Work Affiliation

Recruited By *

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 *

Expiration Date *

Security Code *

Account # *

Address associated with payment method *

Address Line 1

City

State

Zip Code

Dues Structure: NATIONAL and LOCAL DUES both Must be Paid in FULL to be a Member in Good Standing

National Dues *

Local Dues *

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

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