Student Application

To become a member, please take the time to fill out the information below.

I am a

Student

Full Name

I am

Renewing New

Address:

Phone:

School

Experience in Nursing

Less than 2 years 2-5 years 6-10 years 11-15 years 16-20 years More than 20 years

What is your Gender:

Male Female Other

Highest Degree Held

Associate Degree Baccalaureate in Nursing Another Baccalaureate Master's in Nursing Another Master's Doctorate in Nursing Other

Professional Organization Membership

American Nurses Association American Association of Critical Care Nurses National League of Nursing Chi Eta Phi American Public Health Association American Academy of Nursing Other

Age (Will Remain Confidential)

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+

Please upload a copy of your nursing school acceptance letter.

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We appreciate your interest in our organization and invite the opportunity to partner and collaborate.

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1618 Alhambra Blvd, # 160494 Sacramento, CA 95816
capitolcitybna@gmail.com
(916) 248-0853

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