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UNIVERSITY OF CONNECTICUT SCHOOL OF BUSINESS EXECUTIVE EDUCATION PROGRAM The Business Mastery Program for Public Service Professionals 2012 APPLICATION DEADLINE JANUARY 30 2012 Application Form CERTIFICATE PROGRAM Spring 2012 - PLEASE PRINT NAME Last First MI SOCIAL SECURITY -- PeopleSoft EmpID if known MAILING ADDRESS Street City State Zip PHONE Home // EMAIL GENDER Female Work // Type Home Male ETHNIC GROUP American Indian Asian Business Other BIRTHDATE // Black Hispanic White N/A JOB TITLE AGENCY If you are a University employee are you applying for a tuition waiver Yes No CURRENT STUDENT STATUS Please check one. Not currently enrolled Graduate Student UConn Graduate Student STUDENT STATUS REQUESTED Type of credit requested Undergraduate Graduate Graduate credit requires a transcript from the school where you completed your undergraduate degree to complete your registration. PROGRAM FEES current rate for School of Business courses Undergraduate Credit 4 credits 1 643 per course Graduate Credit 3 credits 2 040 per course For payment and refund policies please go to our website www. UNIVERSITY OF CONNECTICUT SCHOOL OF BUSINESS EXECUTIVE EDUCATION PROGRAM The Business Mastery Program for Public Service Professionals 2012 APPLICATION DEADLINE JANUARY 30 2012 Application Form CERTIFICATE PROGRAM Spring 2012 - PLEASE PRINT NAME Last First MI SOCIAL SECURITY -- PeopleSoft EmpID if known MAILING ADDRESS Street City State Zip PHONE Home // EMAIL GENDER Female Work // Type Home Male ETHNIC GROUP American Indian Asian Business Other BIRTHDATE // Black Hispanic White N/A JOB TITLE AGENCY If you are a University employee are you applying for a tuition waiver Yes No CURRENT STUDENT STATUS Please check one. Not currently enrolled Graduate Student UConn Graduate Student STUDENT STATUS REQUESTED Type of credit requested Undergraduate Graduate Graduate credit requires a transcript from the school where you completed your undergraduate degree to complete your registration* PROGRAM FEES current rate for School of Business courses Undergraduate Credit 4 credits 1 643 per course Graduate Credit 3 credits 2 040 per course For payment and refund policies please go to our website www. business. uconn*edu/publicservice Registration for the course will take place after the application deadline of January 30 2012. Courses are subject to cancellation should enrollment fall below a minimum number of participants. By applying to the program I hereby authorize the School of Business to register me for and I commit to complete the above course in The Business Mastery Program for Public Service Professionals. SIGNATURE OF STUDENT Please complete this form and fax to Mary Palmer at 860-486-9102 Mail undergraduate transcript to Mary Palmer Program Manager UConn School of Business Executive Education 2100 Hillside Road U-1041 Storrs CT 06269-1041. Not currently enrolled Graduate Student UConn Graduate Student STUDENT STATUS REQUESTED Type of credit requested Undergraduate Graduate Graduate credit requires a transcript from the school where you completed your undergraduate degree to complete your registration* PROGRAM FEES current rate for School of Business courses Undergraduate Credit 4 credits 1 643 per course Graduate Credit 3 credits 2 040 per course For payment and refund policies please go to our website www. business. uconn*edu/publicservice Registration for the course will take place after the application deadline of January 30 2012.