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Public Health Leader Certificate Application: Name of Supervisor
1. Online Form
Details about the Public Health Leader Certificate can be found at http://www.biosci.utexas.edu/healthit/informatics.asp
IMPORTANT DUE DATES:
FRIDAY, MAY 25, 5 PM:
Submit the name of your supervisor through this form.
MONDAY, JUNE 11, 8 AM:
Submit the online application.
INSTRUCTIONS FOR COMPLETING THIS FORM
Fill out your contact and demographic information below.
Fill in the information about your supervisor. Go to the end of the form and press the "Submit" button. Supervisors will be provided with an online form to submit their letters of recommendation electronically.
For technical questions, contact Dr. Diane Kneeland, email@example.com
For program questions, contact Dr. Leanne Field, firstname.lastname@example.org
. Please provide your contact information:
Please provide your contact information:
. LETTER OF RECOMMENDATION
Your supervisor will be contacted by email to provide an evaluation. The recommendation must be received before June 1 at 5pm.
LETTER OF RECOMMENDATION Your supervisor will be contacted by email to provide an evaluation. The recommendation must be received before June 1 at 5pm.
. Additional or Second Supervisor Reference (OPTIONAL)
Additional or Second Supervisor Reference (OPTIONAL)