Kentucky HIMA Student Ambassador ApplicationKentucky HIMA Student Ambassador Application Applicant InformationName * Name First First Last Last Phone * AHIMA Membership Number * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * Employment InformationAre you currently employed? Yes No Employer Employer Address Employer Address Employer Address Employer Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Employer Phone Employer Email Position Education Information College/University * Major * Program Coordinator Name * Program Coordinator Name First First Last Last Program Coordinator Email * Program Coordinator Phone * Anticipated Graduation Date * Overall GPA * University Address * University Address University Address University Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/PostalReferencesList two references, other than family or clergy, along with their contact information.NOTE: One must be a HIM faculty member in the program which you are currently enrolled.Reference #1 * Reference #1 First First Last Last Email * Phone * Reference #2 * Reference #2 First First Last Last Email * Phone * Describe your professional/business experience. * List any professional association activities that you have been involved with. * In 1,000 words or less, describe why you're interested in participating in the ambassador program. * TranscriptPlease upload a copy of your official or unofficial college transcripts. Transcript Upload(s) * Drop a file here or click to upload Choose FileMaximum file size: 268.44MB If you are human, leave this field blank. SubmitΔ
