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Student Internship Application Form

First Name Last Name

Address City State Zip Code

Country Phone Number Email Address

Age Academic Institution Dept/School

Major Degree Graduation Date

GPA Highest Education Level Achieved HIMSS Member? (Check if Yes)

Certifications (List) HIMSS Experience

Desired Start Date Internship Length Salary? Course Credit?

Preferred Method of Being Contacted Miles Willing to Travel to Worksite

Industry Desired Role(s) Desired Role(s) Desired (continued)


(Press Control to Select Multiple Industries) (Press Control to Select Multiple Roles) (Press Control to Select Multiple Roles)
Biotechnology Vendor Analyst Managed Care
Consulting Firm - Finance Clinical Information Management Management Engineer
Consulting Firm - Government Clinical Management Medical Records
Consulting Firm - Healthcare Clinician Medical Transcription
Government - Healthcare Compliance/Patient Safety Process Improvement
Government - Other Consultant Programmer
Healthcare Payer Data Management/Analysis Project Management
Healthcare Provider - Clinical Educator Quality Assurance
Healthcare Provider - Financial Financial Management Sales/Marketing/Business Development
Healthcare Provider - Other General Management Systems Analyst
Healthcare Vendor - Hardware Government Systems/Network Engineer
Healthcare Vendor - Network Health Information Administrator Telecommunications
Healthcare Vendor - Software/Applications Health Information Manager Web Developer
Healthcare Vendor - Technical Health Information Technology All of the above
Pharmaceutical Vendor Healthcare Informatics
Software Vendor IT/Technology Management
All of the above All of the above

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