Application for NLC Membership

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

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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 Executive    Active Management
Dues:
Active Executive dues are $150 annually. The Chief Nursing Executive, employed by any organization that is a member of HASC, or the Dean/Director of a Registered Nurse education program shall qualify for active membership if he or she is Registered Nurse currently licensed in the State of California. The term "Chief Nursing Executive" shall be defined by each HASC organization. Qualifying organizations include the following: Acute health care facility; Regional/corporate health care organization which manages or consults in more than one(1) facility; Managed care organization/group; Independent out-patient, ambulatory, or home care organization; Independently licensed extended care/skilled nursing facility; Accredited Registered Nursing education program.       Active Management dues are $50 annually. The following qualify for membership: A Registered Nurse employed in a leadership position by an HASC member organization; A Registered Nurse employed by an accredited Registered Nurse education program.
Area Council dues will be forwarded as indicated:
Inland Los Angeles Orange County Ventura/Santa Barbara Northwest San Gabriel
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