CIO Forum Scholarship

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Epic CIO Forum Scholarship Application Form

I. Applicant Information (ALL fields required)
Name:
Title:
Organization:
Address:
City:
State:	Zip:
Phone:	Fax:
Email:
Size of your organization (in beds or covered lives): When was the last time you attended the Fall CIO Forum? How long have you been a CHIME member?

You will be required to submit additional documents on the next page.

Questions or comments? Send an email to staff@cio-chime.org.

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Upcoming Events
	February 20, 2012 CHIME/HIMSS Spring CIO Forum Las Vegas, Nevada
	April 14-17, 2012 Healthcare CIO Boot Camp Gleacher Center at University of Chicago, Chicago, Illinois
	October 13-16, 2012 CHIME Healthcare CIO Boot Camp Renaissance Esmeralda Indian Wells, California
	October 16-19, 2012 CHIME12 Fall CIO Forum Renaissance Esmeralda Indian Wells, California

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