Central Florida
Black Nurses Association, Inc.
Membership Application
Name/ Credentials ___________________________________
Address ___________________________________________
City ____________________________
State _____________
Zip code___________
Home Phone ___________Work _______ Cell ___________
Fax __________________________ E-Mail ____________
Date of Birth _______________________________________
Social Security Number _______________________________
Educational Degree/ Certification ______________________
College/ University ___________________________________
Nursing License Number _________________
State ________
Place of Employment _________________________________
Occupation _________________________________________
Area of Interest ____________________________________
Year Retired _______________________________________
Membership Fee (renewable yearly- December 31)
Local/National _________ RN/LPN ($170.00)
1st Year Grad ($87.50)
Retired ($87.50)
Student ($47.50)
Affiliate ($35.00)
Amount Enclosed $ ____ Signature ___________________
Make check payable to: Central Florida Black Nurses Association
Mail application to:
Ms. Juanita Green, RN
C/o CFBNA Membership Committee
P.
O. Box 585142
Orlando,
FL 32808
