Create a new account
Thank you for registering to become an Belgium Nurse Center Team member. You have 20 minutes to complete the following page.
Username and Password
Please create a username and password that will be used to log into the Members Only section of Belgium Nurse Centerrn.org.
*Desired Username:
*Password:
*Re-enter Password:
Personal Information
	Type in the characters that you see in the above picture
*First Name:
*Last Name:
*Gender:	Male Female
*Email Address:
*Mailing Address:
*City:
County:
*State:	Select State AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
*Zip Code:
*Home Phone:
Business Phone:
*Cell Phone:
Pager:
Fax Number:
*Preferred Method of Contact (please rate 1 through 5):	Home Phone
	Business Phone
	Cell Phone
	Pager
	E-mail
Please indicate which position you are qualified for below:
*Nursing Positions: (you must select at least one)	Registered Nurse
	Advanced Practice Nurse
	Licensed Practical Nurse
	Allied Health Professional
*Working with Pediatric Patients:	Yes No
	* denotes required field.