MEMBERSHIP APPLICATION FOR THE NATIONAL BLACK NURSES ASSOCIATION
 Please type or print legibly

Name:______________________________________Credentials:______________________
Recruited By:_________________________________ Address:_____________________________City________________State_____Zip:_________ Phone: (      )____________  FAX:(      )____________  E-Mail: __________________________
Nursing License Number:__________________________________State:_________________
If Student, Indicate Nursing School:________________________________________________

In order for your NBNA Membership to be activated, both local and national dues must be paid. Please enclose remittance with your completed application.  Mail total payments to appropriate Chapter.  A Chapter Presidents’ listing is attached and  on our website: www.nbna.org. NBNA, 8630 Fenton Street, Suite 330, Silver Spring, MD 20910. Phone: (301) 589-3200; Fax: (301) 589-3223  E-Mail: patgray@nbna.org; nbna@erols.com.

MEMBERSHIP CATEGORIES - CHECK ONE
LIFETIME $2,000__ RN/LPN/LVN  $150 __ STUDENT $35__ 1ST YEAR GRAD $75__  RETIRED $75__
Credit Card Payment:
Master Card/Visa Account Number:___________________________________________________
Exp. Date:__________________ Signature:____________________________________________
How did you hear about NBNA? _____________________________________________________
Please select a local chapter____________________________ No chapter in your area? You will become a direct member, mail your dues to the National Office. Use the Corresponding Number from the NBNA Chapter Listing.

Member Profile: Please Circle The Appropriate Response For The Categories Listed Below:

EXPERIENCE IN NURSING
1.   Less than 2 years  
2.   2 -5 years
3.   6-10 years
4.   11-15 years
5.   15-20 years   
6.   More than 20 years

PRIMARY WORK SETTING
1.   Private Non-Profit Hospital
2.   Public/Federal Hospital
3.   Private, Investor-Owned
      Hospital
4.   School/College of Nursing
5.   Independent/Private
      Practice
6.   Military
7.   Industry
8.   Home Health Agency
9.   Behavioral Care Company
      HMO
10.  Community Agency
11.  Academe
12.  Research
13.  Nursing Home

PRIMARY ROLE
1.   Administrator/Director/or
      VP of Nursing
2.   Head Nurse, Manager, or
      Assistant Head Nurse
3.   Staff Nurse
4.   Advanced Practice Nurse
5.   Researcher
6.   Consultant
7.   Educator
8.   Case Manager

HIGHEST DEGREE HELD
1.   Diploma
2.   Associate Degree
3.   Baccalaureate in Nursing
4.   Baccalaureate or Other
5.   Masters in Nursing
6.   Masters in Other
7.   Doctorate in Nursing
8.   Doctorate in Other

NURSING EMPLOYMENT
1.   Full-time
2.   Part-time
3.   Unemployed
4.   Retired

NURSE PROFILE
1.   ANA Certified
2.   Generalist (RN, C)
3.   ANA Certified
4.   Specialist (RN, CS)
5.   Prescriptive Authority

LEVEL OF CARE PROVIDED
1.   In-patient
2.   Out-patient Ambulatory
3.   Public Health Department
4.   Nursing Home
5.   Residential
6.   Rehabilitative

NOTE: Your responses to the following remain confidential and will only be used in the aggregate for membership profiles.

ANNUAL SALARY
1.   Under $20,000
2.   $20,000-$29,999
3.   $30,000-$39,999
4.   $40,000-$49,999
5.   $50,000-$59,999
6.   $60,000-$69,000
7.   $70,000-$79,999
8.   $80,000 plus

 Nursing Specialty:
_____________________
ER, OR, Diabetes, Oncology, etc.

AGE RANGE
1.   20-24        7.    50-54
2.   25-29        8.    55-59
3.   30-34        9.    60-64
4.   35-39        10.  65 Plus
5.   40-44
6.   45-49

SEX
1.Female      2.Male

PROFESSIONAL ORGANIZATION MEMBERSHIPS
1.  American Nurses
     Association
2.  American Association of
     Critical Care Nurses
3.  National League of Nursing
4.  Chi Eta Phi
5.  American Public Health
     Association
6.  Other:_____________
       National $____________
      Chapter $____________
           Total $____________

PLEASE PRINT A COPY OF THIS APPLICATION AND MAIL WITH CHECK TO THE NBNA.

THANK YOU FOR JOINING NBNA!