All records of applicants will remain confidential and will be used only by PHIMA for purposes of determining eligibility and verifying qualifications.

*AHIMA ID:
*First Name:
*Last Name:
Credentials:	RHIA RHIT CCS CCS-P CCA CHP CHS CHSP None Other:
*Address:
Address (cont'd):
*City:
*State:
*Zip Code:
*Daytime Phone:
*E-mail:

Current Educational Institution

School:
Phone #:
Program Enrolled:	HIT HIA Graduate
Enrollment Status:	Part-time Full-time
Date Studies Began:
Expected Graduation Date:

Educational History

List in chronological order any other post-secondary institutions attended, including 2- year and 4-year colleges, universities, vocational, and professional schools.

School Name	Field of Study	Attendance Dates	Degree

Professional References

List 2 references that will provide letters of recommendation. References should be educators and employers who can provide an evaluation of your professional and academic performance.

Name	Address	Relationship to Applicant

Current Employment

Employer
Supervisor
Address
Length of Employment
Job Responsibilities

Please email resume to scholarship@phima.org

Professional/Volunteer Experience

Briefly describe what it means to be a professional and why you have chosen a career in HIM.

Describe your involvement in local, state or national HIM association and volunteer activities. Please explain your role, give examples.

Describe any other volunteer experiences including community activities you participate in.

Statement of Objectives

Briefly describe what it means to be a professional and why have you chosen a career in HIM?

What do you see as current or upcoming challenges in the field of HIM?

What are your long-term professional goals?

Awards/Honors Received

Statement of Authenticity

I certify that the information above is accurate and authentic.

Additional Documentation

Please email or mail the following:

Two references/recommendations

Copy of a recent transcript of credits from an accredited HIM, HIT, or graduate program

Email: Scholarship@phima.org

Mail:

Cathy A. Flite, M.Ed., RHIA
Temple University
Health Information Management Department
3307 N. Broad Street
Philadelphia, PA 19144

The application, reference, and transcript for the 2008/2009 must be postmarked no later than February 13, 2009.