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Scholarship Application for the Established Professional

Complete the following application and print out this page for your records prior to clicking "Submit Survey" button. Mail proof of payment for books, newsletters, software or CE Certificate of Attendance for seminar registration, tuition or OHIMA event to:

^*1. First Name:

^*2. Last Name:

^*3. Street Address:

^*4. City:

^*5. State:

^*6. Zip Code:

7. Employer:

8. Employer Address:

^*9. Day Phone:

^*10. Evening Phone:

11. Current Position:

^*12. AHIMA ID#:

14. E-mail Address:

^*15. Funds used for:

^*16. Dollar Amount Requested (not to exceed $550):

^*17. Date Expenses Were Incurred:

^*18. New or Current Role Eligible for Scholarship:

Clinical Data Specialist
Patient Information Coordinator
Data Quality Manager
Document and Repository Manager
Research and Decision Support Analyst
Security Officer
Privacy Officer
Tumor Registrar
Other

^*19. Please explain in 500 words or less how this book, newsletter, seminar registration, software program, OHIMA event, tuition, etc. will assist you in your transition to or advancement in roles, such as those roles with the spirit of Vision 2016. Also describe your personal involvement as a role model for life long learning.