Application form for UW certificate program:
Advanced Research in Addiction and the Brain 2008 (Program ID# 2889)

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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.

The 2008 program begins in October 2008. Applications are now being accepted and will be reviewed in the order they are received starting June 2 through August 25, 2008. After August 25, 2008 you are encouraged to call 206-685-8936 or e-mail us to learn if a program is still accepting applications.

Yes, I wish to apply to the UW Advanced Research in Addiction and the Brain Certificate Program. I enclose this completed form with a $50 nonrefundable certificate program fee and my letter of interest.

Note: 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:
Highest earned degree:

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:

Ethnic Origin (Optional)
African American    Asian American    Caucasian    Hispanic    Native American    Other   

How did you first hear about this program?
Ad    Adviser/Recruiter referral    Brochure    Catalog
Friend or colleague    Postcard    Newspaper article/calendar listing
Radio    Web site    E-mail    Other

Mail application/registration materials to the appropriate address below: