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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 File Maximum upload size: 268.44MB If you are human, leave this field blank. SubmitΔ
