Application to the Certificate Program in the Conceptual Foundations of Medicine Return to: History and Philosophy of Science University of Pittsburgh 1017 Cathedral of Learning Pittsburgh, PA 15260 PRINT OR TYPE ALL ENTRIES Name: ______________________________________________________________________ Social Security Number: ______________________ Major: _________________________________________ Present Mailing Address:_______________________________________________________ Phone Number: ____________________________ PERMANENT Mailing Address:__________________________________________________ Phone Number: __________________________________ List post high school academic work (other than the Univ. of Pgh.) including the location, your major, and the degree earned. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Transcripts of all undergraduate study are required. Indicate whether you ____________ have requested (or) ____________ will request that they be sent after all 6 courses have been taken. OVER Indicate the nature of your interest in the program's studies. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ SIGNED: _____________________________________ DATE: ________________________ Rev. 9/99 2