2023 NBNA Conference Speaker Registration Form

2023 NBNA CONFERENCE SPEAKER REGISTRATION FORM
51^stANNUAL INSTITUTE AND CONFERENCE

Tuesday, August 1 - Sunday, August 6, 2023

ALL SPEAKERS MUST COMPLETE THIS FORM

Completion of this form confirms your participation as a speaker.

Please email your 50-word bio to Dianne Mance at dmance@nbna.org.

PHOTO AND BIO MUST BE SUBMITTED BY MAY 15, 2023
Full Name*

PrefixFirst NameLast Name
Credentials*
NBNA Member?*
NBNA Chapter?*
Job Title*
Institution*
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
E-mail*
example@example.com
Signature

Clear
Date

MonthDayYear
Date
Are you Under Forty?

YesNo
Are you an Advanced Practice Nurse?

Yes
Type of Registration

Full Speaker Registration - $390.00One-Day Speaker Registration Fee - $190.00
Payment Method
Mail-in Payment

Check (Made Payable to NBNA)Please send invoice
PLEASE ALLOW 10 DAYS PROCESSING TIME IF PAYING BY CHECK

MAIL

National Black Nurses Association, Inc.

8630 Fenton Street, Suite 910

Silver Spring, MD 20910

FAX or EMAIL

Fax: 301.589.3223 or Email: dmance@nbna.org
Online Payment

Member - Log in to your NBNA Profile to RegisterNon-Member - Complete Online Membership Application, Register as Non-member Speaker for Credit Card Payment or Invoice
Don't delay, book your hotel reservation today!

HILTON ATLANTA Reservations Link:
https://book.passkey.com/go/NTLBlackNurses2023
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2023 NBNA CONFERENCE SPEAKER REGISTRATION FORM