Application/Registration form for UW certificate program:
Basic Bioscience 2010-2011 (Program ID# 3180)

Return to program description

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

The 2010-2011 program begins in January 2010. Applications will be accepted until the program is full. 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. For more information, please call 206-685-8936 or e-mail us.

I wish to apply to the UW Certificate Program in Basic Bioscience. I enclose this completed form, a $50 nonrefundable certificate program fee, and two stapled application sets, which include my résumé and letter of application (see application process).

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 form.
VISA
MasterCard

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

Mail application/registration materials to the appropriate address below:

For materials sent via U.S. mail:
Certificate Program Applications/Registrations
UW Extension Registration Services
PO Box 45010
Seattle, WA 98145-0010

For materials sent via express or courier delivery only:
Certificate Program Applications/Registrations
UW Extension Registration Services
4311 11th Ave. NE, Suite 100
Seattle, WA 98105-4608