Your Name:

Title

Employer/School:

Employer/School Address:

City:

State:

Zip:

Phone:

Fax:

Home Address:

City:

State:

Zip:

Phone:

Fax:

Email:

Preferred Mailing Address:
Business
Home

Preferred E-Mail Address:
Business
Home

Preferred Directory Address:
Business
Home

Would you be interested in becoming a mentor?
Yes
No

Please list areas of expertise:

Would you be interested in becoming a mentee?
Yes
No

Area of interest:

Age:
20-30 31-40 41-50 51-60 61+

Was Nursing Your 1st Profession?
Yes
No

If no, please list previous profession:

Are you a NLN Member?
Yes
No

Do you have an APRN License?
Yes
No

If yes, please specify:

Education: (LPN, AD, BSN, MSN, PhD, EdD, DNSc, DNP, ND)

Degree: Institute: Year Grad.:

Degree: Institute: Year Grad.:

Degree: Institute: Year Grad.:

Are you a faculty member?
Yes
No

If Yes, please specify:
Full-time (FT)
Part-time (PT)

School:
Subject Area(s):

If No, would you be interested in becoming a Faculty member?
Yes
No
FT
PT

Mastercard
Visa

Name On Card:

Credit Card Number:

Credit Card Expiration Date:

City:

State:

Zip: