[current-page:query:title]

[current-page:query:date1] | [current-page:query:ce] contact hrs | [current-page:query:rx] pharmacology hrs* | $[current-page:query:fee] processing fee | [current-page:query:SKU] | Location:  [current-page:query:location]

DIRECTIONS: To request a contact hour certificate, submit this form to the course coordinator at the activity. Successful completion requires completion of all required activities and submission of a completed evaluation form. A link to your certificate will be emailed to you within four weeks.

Please print clearly. All information is required.

Name:________________________________________________________ Highest Degree____________ Mobile Phone____________________________

Address (City, State, ZIP)_________________________________________ Agency Name ____________________________________________________

Email Address__________________________________________________ Your Profession or Specialty ________________________________________

Attestation of Attendance (Required for your certificate)

I successfully completed this activity and earned ________ contact hours. (Maximum you can claim is [current-page:query:ce].)

Date of Activity Completion____________________ Location of Activity (City, State)_______________________________________________________

Certificate Processing Fee: $ [current-page:query:fee]   (If fee is required, make check payable to the University of Washington.)

Your Signature____________________________________________________________________ Date________________________________________

*Pharmacology hours at the advanced practice level.