General Membership Form
Greater New York City Black Nurses Association
General Membership Application
I am:
*
Renewing
New
I am a:
*
RN
LVN/LPN
Retired Member
First Year Graduate
Name
*
First Name
Last Name
Credentials
*
i.e BSN, RN, etc.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Nursing License #
*
State Issued
*
Work affiliation
*
Recruited by:
Experience in Nursing:
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Less Than 2 years
2-5 years
6-10 years
11-15 years
16-20 years
More than 20 years
Level of Care Provided:
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i.e, Inpatient, Outpatient, Public Health Dept., Nursing Home, etc.
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
N/A
Nursing Specialty:
*
i.e, ER, OR, ICU
Nursing Employment:
*
Full-Time
Part-Time
Retired
Unemployed
Primary Role:
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Adm/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
Gender:
*
Male
Female
Non-binary
Highest Degree Held:
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Associate Degree in Nursing
Bachelor of Science in Nursing
Another Baccalaureate
Master of Science in Nursing
Another Master's
Doctorate in Nursing
Other
Professional Organization Membership:
American Nurses Association
American Association of Critical Care Nurses
National League of Nursing
Chi Eta Phi
American Public Health Association
American Academy of Nursing
Other
Age: (Will Remain Confidential)
*
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
Annual Salary (Will Remain Confidential)
*
UNDER - $20,000
$20,000 - $29,000
$30,000 - $39,000
$40,000 - $49,000
$50,000 - $59,000
$60,000 - $69,000
$70,000 - $79,000
$80,000 - PLUS
My Products
prev
next
( X )
RN
$
220.00
LPN/LVN
$
150.00
1st Year Grad
$
165.00
1st Year Grad LPN/LVN
$
130.00
Retired RN/LPN/LVN
$
125.00
Kindly utilize Zelle to send your payment to gnycbna@gmail.com
Have you completed your Zelle payment successfully? If yes, please click "Yes."
*
Yes
Please upload proof of payment.
*
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Please check your email for your GNYC BNA welcome letter
*
Yes
Email
example@example.com
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