HIM Application

 

Program you are applying for: 
 * Full Legal Name: 
 * Address: 
 * City: 
 * State: 
 * Zip Code: 
 * Country: 
 Business Phone: 
 Home Phone: 
 Student ID: 
 Email Address: 
 Emergency Contact Name: 
 Emergency Contact Relationship: 
 Emergency Contact Address: 
 Emergency Contact Phone: 
 Education: High School 
 Education HS City State 
 Education Year Graduated 
 Education College 1 
 Other Names Used   
 College 1 City State 
 College 1 Year Graduated 
 Education College 2 
 College 2 City State 
 College 2 Year Graduated 
 Extra Activities and Dates 
 Employer Name 1 
 Employer City State 1 
 Employment Dates 1 
 Positions Held 1 
 Employer Name 2 
 Employer City State 2 
 Employment Dates 2 
 Positions Held 2 
 Employer Name 3 
 Employer City State 3 
 Employment Dates 3 
 Positions Held 3 
 Employer Name 4 
 Employer City State 4 
 Employment Dates 4 
 Positions Held 4 


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Tell us about your interest in HIM.

 


Employment In Health Department

Tell us about your work experience in
healthcare and/or Health Information.