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Additional information
Nursing License #
Work Affiliation (Place of Employment)
Applicant Category
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1st Year Graduate
LPN/LVN
RN
Retired
Student
Experience in Nursing
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2 – 5 year
6 – 10 years
11 – 15 year
16 – 20 years
Less than 2 years
More than 20 years
Level of Care Provided
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. Nursing Home
. Rehabilitative
. Residential
In-patient
Out-patient Ambulatory
Public Health Department
Nurse Profile
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ANA Certified
Generalist (RN, C)
Prescriptive Authority
Specialist (RN, CS)
Primary Work Setting
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. Independent/Private Practice
Behavioral Care Company/HMO
Community Agency
Home Health Agency
Industry
Military
Nursing Home
Private, Investor-Owned Hospital
Private Non-Profit Hospital
Public/Federal Hospita
Research
School/College of Nursing
Nursing Specialty, i.e., ER, OR
Nursing Employment
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Full-time
Part-time
Retired
Unemployed
Primary Role
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. Adm/Dir./VP of Nursing
. Adv Practice Nurse
Assistant Nurse Manager
Assistant Professor
Associate Professor
Case Manager
Consultant
Educator
LPN/LVN
Nurse Manager
Professor
RN
Researcher
Staff
Highest Degree Held
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Another Baccalaureate
Another Master’s
Associate Degree
Baccalaureate in Nursing
Doctorate in Nursing
Master’s in Nursing
Professional Organization Membership
American Academy of Nursing
American Association of Critical Care Nurses
American Nurses Association
American Public Health Association
Chi Eta Phi
National League for Nursing
Other:
Age Range
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. 65 plus
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55.59
60-64
Membership Status
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New
Renewal
Annual Salary
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$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 - $79,999
$80,000 – PLUS
UNDER $20,000
Date:
Lifetime Membership Payment Option
Pay in Full and local Dues
Full Lifetime dues is $2,000.00 plus Local dues for the chapter you are affiliated with or joining.
Pay in 4 installments of $500.00 plus local dues with the first installment.
1st installment $500.00
2nd installment $500.00
3rd installment $500.00
4th installment $500.00
Donations
Reason for Donation (none, fundraiser, event, support, etc.)
Scholarship General Information
Social Security Number
Race/ Etnicity
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American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Other
White
Annual Income
Spouses Place of Employment
Spouses Annual Income
Current South Jersey Chapter NBNA Student Member?
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No
Yes
Year Joined
Head of Household
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Father
Mother
Other
Self
Others You Support
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1
2
3 or more
Support 1- Name, Age, Relationship, School or Place of Employment
Support 2- Name, Age, Relationship, School or Place of Employment
Support 3- Name, Age, Relationship, School or Place of Employment
Do you currently hold a Nursing License?
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No
Yes
License Type:
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LPN/LVN
RN
If Yes, License Number
If Yes, License State
Source of Income i.e., Family, Scholarship, Grant, Loans, Veterans Benefits, etc.
Receiving other scholarships for the coming school year? Please list the scholarship and amount:
Are you eligible for free tuition or tuition assistance? (check all that apply)
College/University Program (ie. scholarship, grants, etc.)
Employee Program (ie. tuition reimbursement, etc.)
Federal Program (ie. military, pell grant, etc.)
No
State Program
Please name the program and the amount eligible and/or percentage of tuition covered:
Current School of Nursing Enrollment:(Official transcript from school listed below)
School Name
Street Address
Street Address Line 2
City
State
Zip Code
Dean/Director's Name
Dean/Director Email
School Phone
Type of Nursing Program - Please select one:
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ADN RN
Doctorate
Generic BSN (please answer next question)
LPN/LVN
Masters
RN-BSN
For Generic Students: Accepted into the nursing program?
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Does not apply
No
Yes
If in a Doctoral Program, indicate type of degree
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DNP
EdD
Other: Answer next question
PhD
What Doctorate degree are you pursuing?
Focus Area of Nursing
How many years do you have before graduating?
How much will your tuition cost for the 2023-2024 academic year?
Expected Graduation Date:
Advisor:
Do you attend an Historically Black College or University?
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No
Yes
Are you currently enrolled (only being accepted is not eligible to apply)?
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No
Yes
If yes, are you enrolled full-time or part-time?
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Full-time
Part-time
Extracurricular/Community Activities (please list)
I affirm all information given is complete and true. False statement(s) will void application.
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I affirm
I do not affirm
Give consent/willingness to publish photograph in SJCNBNA Publications and/or SJCNBNA website.
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I consent
I do not consent
The sponsor may ask for personal statement and picture of the awardee.
Select
I agree to provide
I disagree to provide
Signature: (Please upload an electronic copy of your signature)
Date:(application completed, submitted and signature uploaded)
Click to upload Personal Statement/Essay
Click to upload Resume or CV
Click to upload letter of recommendation from Dean/Faculty member
Click to upload letter of recommendation from Chapter President/Vice President
Click to upload letter from the Registrar
Click to upload additional letters of recommendation
Click here to upload signed Honors Pledge:
Click to upload additional supporting documents:(Certificates, letters, articles)
DEADLINE: 2/1/2024 - Ensure all the items on this list checked off for being completed or sent:
500-word/2-page Personal Statement/Essay
Current Professional photo (Headshot)
Letter from Registrar verifying enrollment and expected date of graduation
Letter of Recommenation from Dean/Faculty Member
Letter of recommendation from Chapter President/Vice President
Official Transcript - Postmarked by February 1, 2024, and sent directly to NBNA National Office
Resume or CV
Scholarship Application
Signed Honor Pledge
Supporting documents (certificates, letters, articles)
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