Southern Connecticut Chapter of The National Black Nurses
Association, Inc.
Membership Information Form
Name_________________________________________Credentials:___________________
Recruited by________________________________________________________________
Address:___________________________________________________________________
City:_______________________________State:_____________________Zip___________
Phone:___________________________Fax:_________________e-mail:_______________
Nursing Licence Number:____________________________________State:____________
If Student, indicate Nursing School______________________________________________
Dues: Please enclose remittance with your completed application. Checks or money orders should be made payable to SCBNA. Mail application an check to:
SCBNA
P. O. Box 2973
New Haven, CT. 06515
MEMBERSHIP CATEGORIES - CHECK ONE
LIFETIME $2000 _____ RN/LPN $200_____ STUDENT $60 _____ 1st YEAR GRAD $125_____ RETIRED $100 _____
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