KHIMA Distinguished Member Nomination Form Please read over our KHIMA Distinguished Member Award Guidelines before filling out an application. Nominee Information Name * First Last * Last AHIMA ID * Phone Number * Work Address * Street Address City * State * Alabama Alaska Arizona Arkansas 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 ZIP Code * Nominator Information Name * First Last * Last AHIMA ID * Email Address * Phone Number * Address * Street Address City * State * Alabama Alaska Arizona Arkansas 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 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. reCAPTCHA If you are human, leave this field blank. EducationEducation CAHIIM Accredited Programs Credentials Exam Reimbursement Distinguished Member Nomination Form MVP Nomination Form Outstanding Student Award Nomination Form Rising Star Award Nomination Form Speakers Bureau Student Ambassador Student Scholarship Student Scholarship Donation
