What Membership Type are you applying for?*CIO/ExecutiveCorporate Senior IT Executive (direct report)Clinical InformaticsSenior Digital/Innovation LeaderOrganizational - I want to bring my teamNot sure, need more informationPronounHe/Him/HisShe/Her/HersThey/Them/TheirChoose not to identifyName* First Middle Last Suffix Preferred Name Job Title* Designations Work Email* Personal Email For staying in contact if you leave your organization or email convention changes, etc.Date of Birth MM slash DD slash YYYY Current Organization Name* What best describes your organization?*Ambulatory Facility/ClinicBehavioral Health CareCancerGroup Practice/ClinicHealth Insurer/Insurance OrganizationHIEHome Health CareHospiceHospital/Acute Care FacilityIntegrated Delivery System/NetworkLab ServicesLaboratoryManaged CareMSONursing HomeNursing Home/Long Term CareOtherRehabilitationSpecialty Hospital (Childrens)Surgical CenterWhat is your Organizations Gross Revenue*$2B+$1B-$2B$500M-$1B$100M-$500M$50M-$100MUnder $50MWhat is the number of Staffed Inpatient Beds* What is the title of the person you report to?* Work Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Work PhoneCell PhoneAssistant Name First Last Assistant Email LinkedIn Twitter Facebook Job Description*Max. file size: 1 GB.Job description or a brief statement of your areas of accountabilityIT Department Organizational Chart*Max. file size: 1 GB.How did you hear about CHIME?*Privacy Policy* Check here to indicate that you have read and agree to the CHIME privacy policy terms. Privacy Policy- https://chimecentral.org/privacy-policy/ Questions? Contact Us: Should you have other questions or concerns about these privacy policies, please call us at 734.665.0000 or send us an email to [email protected].