Name: ____________________________________________________________________
                Type/Print full given name which will appear on your certificate

Social Security Number: __________________________________

Local Address: _________________________________________________________________
                             Street/Apt.#, City and State/Zip Code

Local Phone Number: ______________________ E-mail Address:_______________________

Permanent Address: _____________________________________________________________
                                      Street/Apt.#, City and State/Zip Code

Home Phone Number: _____________________________

School/College: Nursing Major: Nursing
Agri., Arts & Sci., Educ., Bus. & Econ., Engr., NURS., Technology

Degree__________________________________________ Date Completed/Expected_______

A. List of Suggested Environmental/Waste Management courses:

EASC 201, BIOL 220, CHEM 104, CHEM 114, NURS 524, NURS 510, Special Projects in Environmental Issues,
PSYCH 320, NURS 320, NURS 410, NURS 411, NURS 511, NURS 518

B. Other Environmental/Waste Management experiences (internships, projects completed, volunteer work, etc.)
Attach a statement.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

I understand that to earn a certificate in waste management I must have completed a minimum of 18 credit hours of approved waste management/related courses, and have a minimum GPA of 2.0.

Signature _______________________________________ Date: _____________________