Please complete all the information requested.

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* 1. Demographic

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* 2. Gender:

In chronological order, list all educational institutions attended beginning with high school.

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* 3. High School Name State Country, if not USA Dates of Attendance Graduation Date (month/year)

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* 4. College/ University Name State Country, if not USA

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* 5. College/ University Name State Country, if not USA

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* 6. College/ University Name State Country, if not USA

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* 7. Current Employer/City/State

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* 8. Position/ Years employed

Response to these questions (8 – 10) is voluntary. This information is being collected to meet research and federal reporting requirements. It is confidential and will not be released except in the form of statistical summaries in which individuals are not identified. This information has no adverse effect on either admissions or academic decisions. Which category describes you best? (Check One)

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* 9. Are you Hispanic or Latino?

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* 10. Select one or more of the following five groups:

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* 11. From what country or part of the world did you or your family originally come?

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* 12. What is your motivation for choosing this career/program? What do you hope to gain from this curriculum?

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* 13. How has your prior academic work or employment prepared you to pursue this profession?

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* 14. What do you think will be the most difficult part in enrolling in this program, if anything?

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* 15. How would you handle a scheduling challenge between work, home and your school responsibilities?

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* 16. What do you see yourself doing professionally; 3-5 years from the time you complete this program?

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* 17. What do you know about/thoughts about SUNY Downstate?

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* 18. How would you describe yourself; strengths/weaknesses?

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* 19. Tuition for the entire certificate program is $2835. You may register for each course individually ($315 per course). For payment arrangements please contact the Office of CME at 718-270-2422.

I hereby certify that all the information given in this application is accurate and complete. I understand that all the information contained in this application will be treated confidentially and will be used for institutional purposes only. I realize that failure to provide complete and accurate information may affect my admission. I understand that my application will not be considered until all necessary documents are received by the Office of Admissions.

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* 20. Signature of Applicant

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* 21. Date

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