State Board of Directors Roster Form

National Student Nurse's Association, Inc.

45 Main Street, Suite 606, Brooklyn, New York 11201

(718) 210-0705 FAX (718)797-1186

State Board of Directors Roster Form

Send to NSNA Immediately following Annual Elections

Please note that all students serving as state officers, board members, regional directors, and on state committees etc. MUST be current student NSNA members.

Urgent: Please complete this form immediately after the election of officers. A current state board roster and EIN# (see below) must be received by NSNA before state dues are transmitted via ACH to the state board's bank account. Note that NSNA collects dues for state associations and transfers state dues monthly to the authorized state board bank account.

NSNA adds the names of state leaders to the NSNA database and important mailings and emails go out to state officers. Any change in address should be reported immediately. Please complete all information. In the area marked "Replacing," indicate the name of the individual who held the position prior to this election. Remember to include consultants and staff when applicable.

STATE OF:*

New Board members were elected on (Month/Year)*

Month/day/year

and will take office on (Month/Year)*

Month/day/year

and serve until (Month/Year)*

Month/day/year

EIN (Employer Identification Number; Federal Tax Identification Number):*

State Association Website Address:*

State President

Please check one box and sign this authorization statement.

I authorize NSNA to share my contact info with the other state association presidents. Please note that NSNA takes no responsibility for what happens to your contact info, including your e-mail address, once it is released to third parties.

I authorize

I do not authorize NSNA to share my contact info with the other state association presidents.

I do not authorize

Signature:

PRESIDENT:

Current President:*

First NameLast Name

Membership number:*

Expiration Date:*

MonthDayYear

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number:*

Area CodePhone Number

E-mail:*

Alternate Email

example@example.com

School you attend:*

Do not abbreviate

Campus:*

city and state

VICE PRESIDENT :

Current Vice President:*

First NameLast Name

Membership Number:

Expiration Date:

MonthDayYear

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number:

Area CodePhone Number

E-mail:*

School attended:*

Do not abbreviate

Campus:*

City and State

SECRETARY:

Current Secretary:*

First NameLast Name

Membership number:*

Expiration Date:*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

School you attend:*

Campus:*

TREASURER:

IMPORTANT: Unless otherwise notified, state dues reimbursement information is mailed to the state treasurer. Dues are transferred to the state association bank account via ACH transfers.

Current Treasurer:*

First NameLast Name

Membership number:*

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number:*

Area CodePhone Number

E-mail:*

School you attend:*

Do not abbreviate

Campus:*

City and state

EDITOR/MEDIA DIRECTOR/WEB MASTER ETC.

Current Editor/Media Director/Web Master:

First NameLast Name

Membership number:

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number:

Area CodePhone Number

E-mail:

School you attend:

Do no abbreviate

Campus:

City and state

COMMUNICATION DIRECTOR:

Current Communication Director:

First NameLast Name

Membership number:

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number:

Area CodePhone Number

E-mail:

School you attend:

Do not abbreviate

Campus:

City and State

NOMINATIONS CHAIR:

Current Nominations Chair:

First NameLast Name

Membership number:

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number:

Area CodePhone Number

E-mail:

School you attend:

Do not abbreviate

Campus:

City and state

LEGISLATION/HEALTH POLICY/ADVOCACY CHAIR:

Current Legislation/Health Policy/Advocacy Chair:

First NameLast Name

Membership number:

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number:

Area CodePhone Number

E-mail:

School you attend:

Do not abbreviate

Campus:

City and state

COMMUNITY HEALTH/POPULATION/GLOBAL HEALTH:

Current Community Health/Population/ Global Health:

First NameLast Name

Membership number:

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number:

Area CodePhone Number

E-mail:

School you attend:

Do not abbreviate

Campus:

City and State

BREAKTHROUGH TO NURSING:

Current Breakthrough to Nursing:

First NameLast Name

Membership number:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

School you attend:

Do not abbreviate

Campus:

City and State

EDUCATION:

Current Education:

First NameLast Name

Membership number:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

School you attend:

Campus:

STAFF:

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

CONSULTANT:

Current Consultant:

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

Appointed by:

School or other employment affiliation

Full name of employer

CONSULTANT:

Current Consultant:

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Appointed by:

School or other employment affiliation

Full name of employer

Additional State Representatives

Title:

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

Membership number:

School you attend:

Campus:

Title:

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

Membership number:

School you attend:

Campus: