Awards Committee application form

1. Personal Information *This question is required.

First Name

Last Name

Title / Position

Employing Agency / Institution

Street Address

Room / Floor / Suite

City

State

Zip

Country

Email Address

Work Phone

Home or Mobile Phone

Please enter your individual NLN Member ID.^†
^†Click here to open the NLN member ID lookup page in a new browser window. *This question is required. This question requires a valid number format.

2. Gender *This question is required.

Male
Female

Check all that apply

4. Types of programs/institutions represented by your organization: *This question is required.

5. Personal statements

Briefly describe your experience as a nurse educator or practice clinician. *This question is required.

Briefly describe your previous national association committee experience. *This question is required.

6. I would be willing to be contacted by the NLN for other opportunities. *This question is required.

7. Please attach a current, abbreviated curriculum vitae (no more than 4 single-spaced pages in length) that is supportive of your application, substantiates your primary area of contribution to nursing education, and emphasizes your accomplishments (e.g. involvement in professional organizations, consultation provided, publications, presentations, honors, awards, etc. (Max file size: 500 KB) *This question is required.

File: {{filename}} delete

8. The National League for Nursing (NLN) is a tax-emept, not-for-profit organization. In order to maintain tax exempt status, all interested persons must comply with guidelines and procedures of the NLN conflict of interest policy. In accordance with this policy, I acknowledge that I will disclose any and all actual, potential or perceived conflicts of interest with the NLN or its entities. I also acknowledge that I am responsible to update all disclosure information at such time that any changes occur.

Do you acknowledge the above statement and agree? *This question is required.

Do you have a conflict you wish to disclose? *This question is required.

At the present time, I believe I have no conflict of interest.
At the present time, I am disclosing the following potential, actual, or perceived conflict of interest.
Please explain Please enter an 'other' value for this selection.

Thank you for completing the Awards Committee application form.

Awards Committee application form

Personal and Member Indentification Information