Application form for UW certificate program:
Medical Management 2009-2010 (Program ID# 2969)

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Return to program description

To apply, please print, complete and mail this form with your required materials to the address below.

Single Review Process: The 2009-2010 program begins in September 2009. Applications for this program are now being accepted. The deadline for receipt of applications at UW Extension is 5 p.m. on August 21, 2009. After this date, check the program status box on the right side of the How to Apply page to determine when the program is no longer accepting applications.. Don't hesitate to call 206-685-8936 or e-mail us if you have any questions.

I wish to apply to the UW Certificate Program in Medical Management. I enclose this completed form with a nonrefundable $50 certificate program fee and three copies each of my résumé and letter of application.

It is the applicant's responsibility to make sure that all required materials are submitted with the application. All applicants will be evaluated on the basis of materials submitted.

Mr.    Ms.
Last name:
First name/middle initial:
Social Security # (required):
Date of birth:
Mailing address:
City/State/Zip:
Daytime phone:
E-mail address:

Method of payment:

	Check in U.S. funds made payable to the University of Washington. (Returned checks are subject to a $25 service fee.)
	Third-party payer: separate document (purchase order or letter of authorization to bill) must accompany this application.
	VISA
	MasterCard

Card number:
Expiration date:
Name as it appears on card:
Credit card billing address:
City/State/ZIP
Signature: