Lifetime Membership Application

Lifetime Membership Form
Greater New York City Black Nurses Association

Lifetime Membership Application.
I am:*

Renewing my local chapter dues
New Applicants please go to https://www.nbna.org/ltapppdf to complete and submit your lifetime membership application.
I am a:*

RNLVN/LPNRetired MemberFirst Year Graduate
Name*

First NameLast Name
Credentials *
i.e BSN, RN, etc.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Nursing License #*
Lifetime Membership #
State Issued *
Work affiliation *
Recruited by:
Experience in Nursing:*

Less Than 2 years2-5 years6-10 years11-15 years16-20 yearsMore than 20 years
Level of Care Provided:*
i.e, Inpatient, Outpatient, Public Health Dept., Nursing Home, etc
Nurse Profile:

ANA CertifiedGeneralist (RN, C)Specialist (RN, CS)Prescriptive Authority
Primary Work Setting:*

Private Non-Profit HospitalPublic/Federal HospitalPrivate, Investor-Owned HospitalSchool/College of NursingIndependent/Private PracticeMilitaryIndustryHome Health AgencyBehavioral Care CompanyHMO Community AgencyResearchNursing Home
Nursing Specialty:*
i.e, ER, OR, ICU
Nursing Employment:*

Full-TimePart-TimeRetiredUnemployed
Primary Role:*

Adm/Dir/VP of NursingNurse ManagerAssistant Nurse ManagerAdv Practice NurseResearcherConsultantEducatorCase ManagerRNLPN/LVNProfessorAssociate ProfessorAssistant ProfessorStaff
Gender:*

MaleFemaleNon-binary
Highest Degree Held:*

Associate Degree in NursingBachelor of Science in NursingAnother BaccalaureateMaster of Science in NursingAnother Master'sDoctorate in NursingOther
Professional Organization Membership:

American Nurses AssociationAmerican Association of Critical Care NursesNational League of NursingChi Eta PhiAmerican Public Health AssociationAmerican Academy of NursingOther
Age: (Will Remain Confidential)*

20-2425-2930-3435-3940-4445-4950-5455-5960-6465+
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
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.*

Cancelof
Please check your email for your GNYC BNA welcome letter*

Yes
Should be Empty:

Lifetime Membership Form

Greater New York City Black Nurses Association