Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Email* Cell Phone (for exam purposes if needed only)Undergraduate InformationUndergraduate School* Graduation Date* Month Day Year Undergraduate Degree or Diploma* Graduate InformationGraduate School Graduation Date MM slash DD slash YYYY Graduate Degree or Diploma Professional ExperienceCurrent Position Start Date* MM slash DD slash YYYY Current Job Title* Current Organization* Title of Direct Report within Organization*(i.e. CEO, CIO) Previous Position Start Date* MM slash DD slash YYYY Previous Job Title* Previous Organization* Title of Direct Report within Organization*(i.e. CEO, CIO) How did you hear about CHCIO? Referred by a colleague Website Social Media External Search Statement of Release & AgreementIn furtherance of this application, I hereby release CHIME and its officers, directors, affiliates, agents and employees and the providers of any information about me from any and all liability and agree to save and hold each of them harmless from and against all claims, costs, expenses, demands, actions and liability arising from or relating to acts performed in good faith and without malice in connection with the provision, collection and evaluation of information and opinions, whether or not request or solicited, concerning my application for Certified Healthcare CIO status in the College of Healthcare Information Management Executives.I further represent and warrant that all information provided on this application is accurate and complete and agree that if I am advanced as a Certified Healthcare CIO. I will abide by the CHCIO Professional Standards of Conduct and other rules and that all of the foregoing releases and agreements will remain in effect with respect to any future evaluation of my fitness for continued membership in CHIME.* I agree to the above statement of release and agreement.
