2022 Nurse of the Year Awards Application Form

2022 Nurse of the Year Awards Application Form
Deadline: May 15, 2022
Choose which awards you are applying for:

Administrative Nurse of the Year AwardAdvanced Practice Nurse of the Year AwardNurse Educator of the Year AwardNurse Entrepreneur of the Year AwardNurse of the Year for Community Service AwardNurse Researcher of the Year AwardStaff Nurse of the Year AwardStudent Nurse of the Year AwardUniformed Services Nurse of the Year AwardOutstanding Licensed Practical/Vocational Nurse of the Year Award
To view Nurse of the Year Awards Criteria and General Instructions, CLICK HERE.
Date
Nominee for the Award of
Full Name*

First Name Middle Name or Initial Last Name
Credentials (ie., BSN, MS, PhD, RN, FNP-BC, FAAN)
Daytime Phone Number

Area CodePhone Number
Email Address*
Current Address

Street Address

Street Address Line 2

CityState

Zip Code
Current NBNA Membership I.D.
NBNA Chapter
Select
Nursing License Number
State

Street Address

Street Address Line 2

CityState

Zip Code
Certification
Organization
EDUCATION PREPARATION
Basic Nursing Program
Class of
Accredited Program
Additional Professional Education (Include current school enrollment if applicable)
Student?

YesNo
Current GPA
School
EMPLOYMENT HISTORY
List Positions held for the last ten (10) years and length of time held. Present position first.
Please provide a resume or CV and a one page biographical sketch.
Upload Resume or CV*
Upload Biographical sketch*
NBNA ACTIVITIES, NATIONAL and/or LOCAL CHAPTER LEVEL

List all NBNA offices or committees you have held or served on in the last ten (10) years. Give dates.
National Level Activities:
Local Level Activities
Present Local/ Chapter Office Held
PROFESSIONAL ACTIVITIES IN OTHER ORGANIZATIONS
Include offices held and give dates.
Kindly provide any additional information, which might be helpful to the NBNA Awards Committee in its review of your application, i.e., additional comments, copies of published articles, news releases, research studies, letters of recommendation, copies of certificates, etc.
PERSONAL CAREER STATEMENT INSTRUCTIONS (REQUIRED) - Two Page Maximum

Submit a personal career statement that summarizes your qualifications for the award applied for and provides verifiable evidence of your accomplishments. Include a statement of how your work aligns with the mission of NBNA.
Upload Career Statement*

Upload a File

Cancelof
Upload Additional Files if Necessary*

Upload a File

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Other:
Submit a professional and recent photo (clear picture)*
ATTESTATION and GENERAL RELEASE
- I hereby affirm that all the information provided is complete and true. Any false statement(s) will make my application null and void.
- Consent/willingness to publish photograph in NBNA publications and/or NBNA website.
Signature*

Clear
Date

MonthDayYear
Date
Recommended by:
Your Name as you wish it to appear in the NBNA program Book
Name

First NameMiddle Name or Initial Last Name
Credentials
Job Title
Place of Employment
City, State

Street Address

Street Address Line 2

CityState

Zip Code
NBNA Chapter
Select
Social Media Handle
Should be Empty: