Howard University
Professional Development and Leadership Academy
Hospital Employee Registration Form

Please register only one person per form. Thank You

1. Fill in all boxes
2. Click the "CLICK HERE" button
3. Print
4. Present to your supervisor for certification
5. Fax or mail to specified Academy office

Name (Last, First):   MI:
Mr.  Ms.  Dr.
Social Security Number: - -
Birthdate (M/D/Y):

Home:
Street Address: Apt:
City:   State:   Zip:
Telephone:

Office:
Organizational Unit:
Department:
Your title:
Mailing Address:

City:   State:   Zip:
E-Mail Address:
Telephone:
Fax No:

Please register me for the following course(s):
Course No./Section Course Title Date

Have you taken other courses at HU Academy? Yes  No

TO REGISTER:

By Fax: (202) 588-9871
By Mail: Howard University Professional Development and
Leadership Academy
2225 Georgia Avenue, NW, Room 304
Washington, DC 20059

For Further Information - Call (202) 238 - 2564