Rising Star Award Nomination Form

2020 KHIMA Rising Star Award

Please read over our KHIMA Rising Star Award Guidelines before filling out an application.

If you are human, leave this field blank.

Nominee Information

Name *

First

Last Name *

Last

Job Title *

AHIMA ID *

Phone Number *

Work Address *

City *

State *

ZIP Code *

Number of years in the HIM profession *

Nominator Information

Name *

First

Last Name *

Last

AHIMA ID *

Email Address *

Phone Number *

Address *

City *

State *

ZIP Code *

Education

Please list the nominee's education credentials. *

Leadership

Credentials *

Awards/Recognitions *

Leadership Roles *

Reason for Nomination

Please explain why you have selected this nominee. *

Signature

Nominator's Signature *

Date *

Application Deadline is May 1st, 2020.

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