NSNA Leadership University Certificate Request Form

NSNA Leadership University Certificate Request Form

- To be completed by Faculty
Attention Graduating Seniors:

School, state and national association leaders who have received academic recognition for their participation in the National Student Nurses' Association are eligible to receive a personalized Leadership University certificate. The faculty member who awarded the academic recognition will also receive a certificate. Certificates are requested by and are mailed to the faculty member who completes this form.

Leadership University participants attending the NSNA Annual Convention will be asked to stand and be recognized at the Opening Ceremony. For details about the convention, go to www.nsna.org and click on meetings. Certificates are no longer distributed at the Annual Convention.
Full Name of Faculty Member completing this form *

First Name Last Name
Title *
Full Name of School as it will appear on certificate *

Address for mailing certificates (forms will be sent to the attention of the faculty member submitting this form) *

E-mail *
Phone Number *

Area Code Phone Number
What date do you need the certificate(s) by? *

Month Day Year Date Picker Icon
Attach an EXCEL spread sheet with the following: Name of student(s); NSNA membership number; expiration date; and date of graduation *
Please provide a brief description of what your student(s) did to receive academic recognition (i.e. describe leadership activities) *
By completing this field you verify that the student(s) has received academic recognition for NSNA participation *

First Name Last Name
Thank you for supporting NSNA

and the Leadership University!
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