2017 KHIMA Distinguished Member Nomination Form

Please read over our KHIMA Distinguished Member Award Guidelines before filling out an application.

Nominee Information

First
Last
Street Address

Nominator Information

First
Last
Street Address

Education

Association Activities

Please separate activities with a comma.
Please separate activities with a comma.
Please separate activities with a comma.
Please separate associations with a comma.

Contributions

If more than one, please separate using a comma.
If more than one, please separate using a comma.

Signature

Full Name
Application Deadline is May 15th, 2017.