Health Information Management Program

ALABAMA STATE UNIVERSITY

HEALTH INFORMATION MANAGEMENT PROGRAM

APPLICATION FOR ADMISSION

 

Name


SEX:
Ethnic Information

Birthplace:

Are you a U.S. Citizen?
Are you a resident alien?

EDUCATION

College/University
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Dates Attended
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Major
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Degree
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Date of Degree
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Are you currently enrolled at Alabama State University
If not, have you applied for admission to the university
Were you:
DatesFrom / To
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Employer/Address
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Position
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Hours/wk
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Dates
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Honors, Awards and Community Service
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REFERENCES

Name and Address
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Telephone
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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
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Date to be Completed
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College/University
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 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

 


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