KHIMA Distinguished Member NominationKHIMA Distinguished Member Nomination Nominee InformationName * Name First First Last Last AHIMA ID Number * Email * Phone * 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 Please list the nominee's education credentials. * Nominator InformationName * Name First First Last Last AHIMA ID Number * Email * Phone * 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 Why have you chosen to nominate this distinguished member? * Association Activities Local Level * State Level * National Level * Other Affiliated Associations Contributions Publications Teaching in AHIMA Approved Education Programs Other HIM Instructions Other Contributions to Professional "Image" Not Classified Elsewhere Other Contributions Signature * Clear Signature of * Date * If you are human, leave this field blank. SubmitΔ
