Application Form

Six-Day Introductory Epidemiology Course
Tougaloo College
Tougaloo, Mississippi

July 12-17, 1999

Please type or print the information requested.

Name: _____________________________________ Degree: ________________

Academic Institution: _____________________________________________________________

Your Mailing Address:

_____________________________________________________________

_____________________________________________________________

If different from above, please provide an address where you can be reached after June 1, 1999.

_____________________________________________________________

_____________________________________________________________

Phone: __________________ Fax: __________________ E-mail: _________________________


_____  Check here if housing on campus is desired.

If accepted, I will participate in the full course beginning with registration at 8:30 a.m. on Monday, July 12 through noon on Saturday, July 17, 1999. If for any reason I am unable to attend the course, I will notify the organizers by June 30, 1999, so they will have time to accept another worthy candidate.

Signature: _____________________________________ Date: ________________

Return your completed application and brief letter to any of the individuals at the institutions listed on the reverse side.

APPLICATION MUST BE RECEIVED BY JUNE 1, 1999.



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