I refer the following candidate for membership in CHIME:Name:* First Last Title:* Firm:* Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:*Fax:*Email:* Website:* Part I: Candidate InformationIs this candidate the highest-ranking clinical IS executive at your organization?* Yes No Is this candidate's organization a direct healthcare provider (ie, hospital, group practice) or payer (HMO, health insurance) and not a vendor or an association?* Yes No To whom does this candidate report?* Is this candidate employed by their organization and not by a third party?* Yes No * I verify that the above information is true and accurate. Part II: Statement of RecommendationIn order for the candidate to be considered for membership, please provide a statement of recommendation. This statement should attest to the candidate's credentials and explain that the candidate meets our current membership criteria and is unquestionably qualified for membership in CHIME. Please write the statement in the text below.Statement of Recommendation:*Recommender's InformationRecommender's Name:* First Last Recommender's Organization:*
