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Health Physics Certification Review Course Application
Please type or print.
Send application with purchase order or check made out to BWC-HPS, to Fred Ferate, Chairman,
Education & Training Committee, P.O. Box 23466, Washington, DC 20026.
Please indicate your preference: ____ Resident Course ____ Correspondence Course
if correspondence, please indicate which address you want us to send your materials to.
Name: ___________________________________________________
Job Title: _________________________________________
HOME ADDRESS
Street:
________________________________________________________________________________________
City:_________________________________ State:________ ZIP:______________
Telephone Number:________________________
BUSINESS ADDRESS
Company:
________________________________________________________________________________________
Street:
________________________________________________________________________________________
City:_________________________________ State:________ ZIP:______________ Telephone
Number:________________________
E-MAIL ADDRESS
________________________________________________________________________________________
Applicant’s Signature: ____________________________________________________
Date: _________________________________
FOR FURTHER INFORMATION CONTACT:
Fred Ferate, Chairman, Education & Training Committee,
Baltimore-Washington Chapter, at (202) 366-4498, or at fred.ferate@rspa.dot.gov.
OR - register on-line at the Baltimore-Washington Chapter Health Physics Society
homepage at http://www.bwchps.org.