Piedmont Black Nurses Association

Member Application

To Join Us

Prefix

First Name

Middle Name

Last Name

Suffix

Birth Month/Day

Title

Company

Address Type

Address

Address Line 2

City

State

Zip

Phone

Website

Mobile

Fax

Individual Online Directory Description

Referred By

Nursing License State

Nursing License Number

Nursing Credentials

Experience in Nursing

Primary Role

Nurse Profile

Gender

Primary Work Setting

Level of Care Provided

Other Professional Organization Membership

Nursing Specialty

Nursing Employment Status

Highest Degree Held

Age Range

Annual Salary

Attended NBNA Day on Capitol Hill Year(s) - Format: yyyy, yyyy, yyyy

Attended Conference Year(s) - format: yyyy,yyyy,yyyy