Become A Member – Black Nurses Association of Austin

Become A Member

Complete the application below.

If you wish to complete a paper application. Click Here to download the form.

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Web Site

Chapter Name *

Application Type *

New Member

Renewing

Lifetime Member

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Phone *

Email *

Nursing License #

State

If student, enter name of nursing school:

Recruited By:

Experience In Nursing

Experience In Nursing

Less than 2 years

2 – 5 years

6 – 10 years

11 – 15 years

16 – 20 years

More than 20 years

Primary Work Setting

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

Nursing Specialty, i.e., ER, OR, Oncology

Primary Role

Primary Role

Administration/Director/VP of Nursing

Nurse Manager, Assistant Nurse Manger

Nursing Supervisor

Advance Practice Nurse

Researcher

Consultant

Educator

Case Manager

RN

LPN/LVN

Staff

Highest Degree Held

Degree Held

HS Diploma

Associate Degree

Baccalaureate in Nursing

Other Baccalaureate

Masters in Nursing

Other Masters

Doctorate in Nursing

Other Doctorate

Nursing Employment

Nursing Employment

Full-Time

Part-Time

Unemployed

Retired

Nurse Profile

Nurse Profile

ANA Certified

Generalist (RN, C)

Specialist (RN, CS)

Prescriptive Authority

Gender

Female

Male

Level of Care Provided

level_of_care1

In-Patient

Out-Patient Ambulatory

Public Health Department

Nursing Home

Residential

Rehabilitative

Professional Organization Memberships

professional_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

Organization Name

NOTE: Your response to the following will remain confidential and will only be used in the aggregate for membership profile.

Age Range

age

20 – 24

25 – 29

30 – 34

35 – 39

40 – 44

45 – 49

50 – 54

55 – 59

60 – 64

65+

Annual Salary

Salary

Under $20,000

$20,000 – $29,000

$30,000 – $39,999

$40,000 – $49,999

$50,000 – $59,999

$60,000 – $69,999

$70,000 – $79,999

$80,000+

National Membership

Lifetime National Dues – $2000.00 or 4 installments of $500.00 before May 18th

National Dues RN – $225.00

National Dues LPN/LVN – $175.00

National Dues RETIRED – $112.50

1st YEAR GRAD – $150.00

National Dues *STUDENT – $50.00

Local Chapter Membership

Local LT Dues to chapter after initial LT payment – $____________

National Dues RN – $___________

National Dues LPN/LVN – $___________

National Dues RETIRED – $__________

1st YEAR GRAD – $____________

National Dues *STUDENT – $___________

Payment Type

Check/Money Order Credit Card PayPal

Credit Card Number

Exp Date

CVC