Application for NLC Membership

To apply for membership, please fill out the form below and click "Submit." Required fields are listed in red.

Please DO NOT enter any information in this field, as it is used to trap spam.
Name:
Position / Title:
Healthcare Organization:
Organization Address:
City, State, Zip:
Phone:
Fax:
E-mail:
Previous Position / Title:
Organization:
City, State:
Dates Employed:	From       To
Personal Information:
Home Address:
City, State, Zip:
Phone:
Fax:
E-mail:
Please indicate mailing address preference:
Office           Home
For first time members: please answer the following questions:
Who was your referral source?
Why are you interested in joining NLC?
Membership Category:    Active    Associate
Dues:
Active member dues are $150 annually. Active members must be the chief nursing leader, as defined by each organization,employedin a member organization of HASC and must possess a valid Registered Nurse License.       Associate member dues are $50 annually. Associate members must be a registered nurse in a leadership position employed in a member organization of a HASC area or an accredited Registered Nursing program.
(Area Council dues will be forwarded as indicated.)
Please make checks payable to:
Nursing Leadership Council
and send to:    ATTN:  Human Resources Coordinator 515 South Figueroa Street Suite 1300 Los Angeles, CA 90071