[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.