Date________________

Social Security Number___________________________

Name (first, last and middle initial)_____________________________________________

Address:
Street & Number____________________________________________________________

City______________________________________________________________________

Zip Code_________________

Telephone (Home)_____________________________________

Telephone (Work)_____________________________________

E-mail Address ______________________________________

UWM Status on entering Certificate Program: Degree: _____ Non Degree: ________

If Degree Status, UWM Department: _________________________ Graduate Advisor: ____________________

Highest Degree Earned (check one): BA/BS_____ MA/MS _____ Ph.D. _____ LLD/JD _____ M.D. _____

Other (specify) ________________________

School/College: ________________________________________

Department: ___________________________________________

Area of Concentration: _________________________________

UPON COMPLETION OF THE ABOVE PLEASE FORWARD THIS FORM TO:

Department of Communication
Graduate Certificate Program in Mediation & Negotiation
University of Wisconsin-Milwaukee
Merrill Hall 146A
P.O. Box 413
Milwaukee, WI 53201-0413

Tel: (414) 229-2255
Fax: (414) 229-4261
e-mail: mediate@uwm.edu