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MEMBERSHIP APPLICATION REQUEST

General Information

First Name:
Last Name:
Credientials:
Recruited By:
Address:
City/State:   
Zip Code:
Telephone:
Fax:
Email:
Confirm Email:
No. of Nursing Licenses:
List State(s) Licenses Held:
If Student, Indicate
Nursing School:

Membership Profile

Membership Type: New Renewal
Please indicate the appropriate responses for the categories
listed below:
How did you hear about NBNA:
Nursing Experience:
Primay Work Setting:
Primay Role:
Highest Degree Held:
Nurse Profile: ANA Certified
Generalist (RN, C)
Specialist (RN, CS)
Prescriptive Authority
Employment Status:
Level of Care Provided
Annual Salary:
NOTE: Your response will remain confidential and will only be used in the aggregate for membership profiles.
Age:
Gender:
Profesional Organization Membership: American Nurses Association
American Association of Critical Care Nurses
National League of Nursing
Chi Eta Phi
American Public Health
Association
Other

I hereby apply for membership to the Black Nurses Association of Greater Kansas City Area and agree to pay the current applicable membership dues. I affix my signature to this on-line application by typing my full name below.

Submit Application

Click one of the buttons below to submit your application.

Lifetime Membership: $2100 (Includes $100 to Kansas City Chapter and scholarship commitment)
RN/LPN/LVN: $325 (Includes $100 to Kansas City Chapter and scholarship commitment)
Student: $110 (Must not have nursing license; Includes $45 to Kansas City Chapter)
First Year Graduate: $250 (Includes $100 to Kansas City Chapter and scholarship commitment)
Retired:$100 (Includes $100 to Kansas City Chapter and scholarship commitment)

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