Fillable Form 1: 2022 NEW / RENEWAL MEMBERSHIP APPLICATION

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Form 1: 2022 NEW / RENEWAL MEMBERSHIP APPLICATION

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EXPERIENCE IN NURSING
PRIMARY WORK SETTING
PRIMARY ROLE
HIGHEST DEGREE HELD
NOTE: Your responses for age
1. Less than 2 years
1. Private Non-Profit Hospital
1. Adm/Dir./VP of Nursing
1. Associate Degree
and salary will remain confidential.
2. 2 – 5 year
2. Public/Federal Hospital
2. Nurse Manager
2. Baccalaureate in Nursing
AGE RANGE
3. 6 – 10 years
3. Private, Investor-Owned
3. Assistant Nurse Manager
3. Another Baccalaureate
1. 20-24 6. 45-49
4. 11 – 15 years
Hospital
4. Adv Practice Nurse
4. Master’s in Nursing
2. 25-29 7. 50-54
5. 16 – 20 years
4. School/College of Nursing
5. Researcher
5. Another Master’s
3. 30-34 8. 55.59
6. More than 20 years
5. Independent/Private Practice
6. Consultant
6. Doctorate in Nursing
4. 35-39 9. 60-64
LEVEL OF CARE PROVIDED
6. Military
7. Educator
Other:
5. 40-44 10. 65 plus
1. In-patient
7. Industry
8. Case Manager
PROFESSIONAL ORGANIZATION
ANNUAL SALARY
2. Out-patient Ambulatory
8. Home Health Agency
9. RN
MEMBERSHIP
1. UNDER $20,000
3. Public Health Department
9. Behavioral Care Company/HMO
10. LPN/LVN
1. American Nurses Association
2. $20,000 - $29,999
4. Nursing Home
10. Community Agency
11. Professor
2. American Association of Critical
3. $30,000 - $39,999
5. Residential
11. Research
12. Associate Professor
Care Nurses
4. $40,000 - $49,999
6. Rehabilitative
12. Nursing Home
13. Assistant Professor
3. National League for Nursing
5. $50,000 - $59,999
NURSE PROFILE
Nursing Specialty, i.e., ER, OR
14. Staff
4. Chi Eta Phi
6. $60,000 - $69,999
1. ANA Certified
SEX
5. American Public Health Association
7. $70,000 - $79,999
2. Generalist (RN, C)
NURSING EMPLOYMENT
1. Female
6. American Academy of Nursing
8. $80,000 – PLUS
3. Specialist (RN, CS)
1. Full-time 3. Retired
2. Male
7. Other:
4. Prescriptive Authority
2. Part-time 4. Unemployed
Dues Structure: NATIONAL and LOCAL DUES both Must be Paid in FULL to be a Member in Good Standing
National Dues
RN - $160.00
National Dues
LPN/LVN - $125.00
National Dues
Retired - $100.00
National Dues
1
st
Year Grad - $150.00
National Dues Student
(Unlicensed SN $35.00)
National amount
$
Local Dues
$
Local Dues
$
Local Dues
$
Local Dues
$
Local Dues
$
Local Dues
$
Lifetime amount
$
TOTAL AMOUNT DUE
$
METHOD OF PAYMENT: is the credit card associated with the address listed above, if NO type or write the address below
Check
Money Order
VISA
Master Card
Expiration Date: ____/_____
Sec. Code: ______
Account #:
Signature:
Address:
THANK YOU FOR YOUR INTEREST IN NBNA
2022 NEW / RENEWAL MEMBERSHIP APPLICATION
Date of Application _______________
Chapter You are Joining _________________________________
Estella A. Lazenby, CMP, Membership Services Manager
8630 Fenton Street, Suite 910
Silver Spring, MD 20910
Email: elazenby@nbna.org
Telephone: (240) 460-6893
New Renewing Year you became a Lifetime Member: ____________
Please type or write legibly, submit your application directly to your chapter or complete your membership
application online. Go to www.nbna.org create your username, password and complete your online profile, pay the
amount due and click submit.
Name: ________________________________________________ Credentials: _____________________________
RN
LPN/LVN
Retired member
1
st
Year Grad
Student
Address:
City/State/Zip Code:
Phone:
E-Mail:
Nursing License #:
State:
Work Affiliation:
Recruited by:
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Form 1: 2022 NEW RENEWAL MEMBERSHIP APPLICATION

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Completed 25 June 2022

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