KHIMA Distinguished Member Nomination Form - Kentucky Health Information Management Association

Nominee Information

Name *

First

Last *

Last

AHIMA ID *

Phone Number *

Work Address *

Street Address

City *

State *

ZIP Code *

Nominator Information

Name *

First

Last *

Last

AHIMA ID *

Email Address *

Phone Number *

Address *

Street Address

City *

State *

ZIP Code *

Why have you chosen to nominate this distinguished member? *

Education

Please list the nominee's education credentials. *

Association Activities

Local Level *

Please separate activities with a comma.

State Level *

Please separate activities with a comma.

National Level *

Please separate activities with a comma.

Other Affiliated Associations

Please separate associations with a comma.

Contributions

Publications

If more than one, please separate using a comma.

Teaching in AHIMA approved education programs

If more than one, please separate using a comma.

Other HIM Instructions

Other Contributions to professional "image" not classified elsewhere

Other Contributions

Signature

Name *

Full Name

Date *

Application Deadline is June 1st, 2020.

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