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NBNA Membership Application
Miami Chapter Black Nurses
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NBNA Membership Application
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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
*
RN
LPN/LVN
Retired Member
1st Year Grad
Student
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Iowa
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Maine
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South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email
*
Nursing Liscense #
Work Affiliation
Recruited By
*
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
Military
Industry
Home Health Agency
Behavioral Care Company/HMO
Community Agency
Research
Nursing Home
Nursing Specialty
Nursing Employment
Full Time
Part-Time
Retired
Unemployed
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
*
Check
Money order
Visa
Master Card
Expiration Date
*
Security Code
*
Account #
*
Address associated with payment method
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Dues Structure: NATIONAL and LOCAL DUES both Must be Paid in FULL to be a Member in Good Standing
National Dues
*
RN – $160.00
LPN/LVN – $125.00
Retired – $100.00
1 st Year Grad – $150.00
(unlicensed SN $35.00)
Local Dues
*
RN – $75.00
LPN/LVN – $75.00
Retired – $25.00
1 st Year Grad – $25.00
unlicensed SN $10.00
All dues expire on 12/31 of each year. Membership dues are tax-deductible. (Donations are accepted).
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