Black Nurse of the Year Nomination Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.General InformationSubmission DateFull Name *FirstLastStreet AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhonePreferred Email *Years in the BNA-GWDCA License InformationRN License StateI have a valid LPN License in my statePlease indicate whether you currently hold an active Licensed Practical Nurse (LPN) license in your state.RN License NumbersRN Expiration DateLPN License StateI have a valid LPN License in my statePlease indicate whether you currently hold an active Licensed Practical Nurse (LPN) license in your state.LPN License NumbersLPN Expiration DateNBNA Membership ID CredentialsSpecialty:Education PreparationBasic Nursing Program Graduation Date Additional Professional Education (include current enrollment if applicable) DegreeInstitutionCompletion Date Employment HistoryList positions held for the last five (5) years, including length of time. Start with current position. If retired, indicate the official date of retirement and the institution the applicant retired from.PositionInstitution/AgencyDates File Upload Drag & Drop Files, Choose Files to Upload You can upload up to 5 files. Please upload any supporting documents for the Black Nurse of the Year Nomination using the upload field below. Accepted file types are .doc, .docx, and .pdf only. Make sure your file is in one of these formats before submitting your form.Certification and AgreementCheckboxes *I certify that all the information provided is accurate and truthful.Checkboxes *I (the nominee) give permission to BNA-GWDCA and the nominator to be considered as a Nurse of The Year awardee.Signature * Date Membership Layout Date of Signature *Submit
