2024 Under 40 Awards Nomination Form

2024 Under 40 Awards

NBNA Salutes Its Next Generation of Nursing Leaders
Deadline: April 15, 2024
NOMINATOR'S CONTACT INFORMATION
Name

PrefixFirst NameLast Name
NBNA Chapter*
Email Address*
Phone Number*
NOMINEE'S INFORMATION
Nominee's Name*
Credentials *
Date of Birth*
Phone*
Email*
Place of Employment*
City and State*

Street Address

Street Address Line 2

CityState

Zip Code
NBNA Chapter*
What year did you join NBNA?*
NOMINEE'S MENTOR INFORMATION

Please provide the information below.
Mentor Name

PrefixFirst NameLast Name
Mentor Email
NOMINEE'S ACADEMIC INFORMATION
Name of Graduate School, if applicable
Degree you are pursuing
Number of hours to complete program
Expected Graduation Date
City and State*

Street Address

Street Address Line 2

CityState

Zip Code
How does the nominee demonstrate a commitment to nursing excellence in practice and in the community (75 words or less)?*
NOMINEE'S AWARDS AND INVOLVEMENT
Chapter Leadership*
Community Leadership*
All awards or honors received (75 words or less)*
Tell us what NBNA has meant to you (75 words or less)*
Professional Accomplishments*
How does the nominee demonstrate earnest leadership beyond having a nursing title (75 words or less)?*
What is your 10 year career plan (50 words or less)?*
Documentation of Professional, chapter, and community accomplishments (not to exceed 2 pages)*

Upload a File

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BIO*

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Current Professional Photograph*

Upload a File

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Can we contact your University or Employer?*

YesNo
Name

PrefixFirst NameLast Name
Email Address
May NBNA interview you at the conference?*

YesNo
May we post your bio and photo on the NBNA website?*

YesNo
May we share your comments on the NBNA website, Facebook page and Twitter?*

YesNo
Social Media Handle
YOUR NAME AS YOU WISH IT TO APPEAR IN THE NBNA PROGRAM BOOK
Name*

First NameMiddle Name or InitialLast Name
Credentials*
Job Title*
Place of Employment*
City, State*

Street Address

Street Address Line 2

CityState

Zip Code
NBNA Chapter*
Should be Empty: