Health Information Management Program

ALABAMA STATE UNIVERSITY

HEALTH INFORMATION MANAGEMENT PROGRAM

APPLICATION FOR ADMISSION

 

I am applying for Fall 20

Student Identification Number

Name

Last

First

Middle

Maiden

Current Local Address

Permanent Mailing Address

City

State

Zip

Daytime Telephone

Evening Telephone

Cellular

E-mail address

Person or relative to notify in case of emergency

Relationship

Telephone

Address

City

State

zip

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If you are a U.S. citizen or a permanent resident of the U.S., please submit the following racial/ethnic information. This information is voluntary and does not affect the application process. Refusal to provide it will not subject you to any adverse consequences. Please indicate your responses below:

SEX:

Male

Female

Ethnic Information

Black/Non-Hispanic

White/Non-Hispanic

Hispanic

Asian or Pacific Islander

Native American or Native Alaskan

Other…

Enter other…

Birthplace:

City

State

Country

Birth Date

Are you a U.S. Citizen?

Yes

No

If not, of what country are you a citizen?

Are you a resident alien?

Yes

No

If yes, give alien registration No

EDUCATION

Please list in chronological order any colleges or universities attended.

College/University

College/University
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Dates Attended

Dates Attended
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Major

Major
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Degree

Degree
	Degree	Item weight	Add Remove

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Date of Degree

Date of Degree
	Date of Degree	Item weight	Add Remove

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Are you currently enrolled at Alabama State University

Yes

No

If not, have you applied for admission to the university

Yes

No

Were you:

Admitted

Denied

Awaiting notification

Other (specify)

Enter other…

HEALTH INFORMATION RELATED WORK OR VOLUNTEER EXPERIENCE (including summer work)

DatesFrom / To

DatesFrom / To
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Employer/Address

Employer/Address
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Position

Position
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Hours/wk

Hours/wk
	Hours/wk	Item weight	Add Remove

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Dates

Dates
	Dates	Item weight	Add Remove

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Honors, Awards and Community Service

Honors, Awards and Community Service
	Honors, Awards and Community Service	Item weight	Add Remove

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REFERENCES

List the names of three people requested to complete recommendation forms. Forms are to be mailed to the address on the recommendation.

Name and Address

Name and Address
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Telephone

Telephone
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Position/Title

Position/Title
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List any prerequisite courses not completed. Indicate planned date for completion prior to entering the Health Information Management Program.

Course Number & Title

Course Number & Title
	Course Number & Title	Item weight	Add Remove

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Date to be Completed

Date to be Completed
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College/University

College/University
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You will be notified the date of your interview. Essays will be required and your topic for essay will be given at the time of the interview.

Applicant Signature:

Date

 Mail application to the following address:

• Department of Health Information Management
• Alabama State University
• P.O. Box 271
• 915 South Jackson Street
• Montgomery, AL 36101-0271

 

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Application may be hand delivered to:

• Department of Health Information Management
• John Buskey Health Sciences Center
• Suite 201
• Alabama State University
• Montgomery, AL 36101
• Phone 334.229-5058
• Fax: 334.229-5880

Submit