> IRTPHIapplication
IRTHI Application Form

Training Track:
Masters in Science in Health and/or Biomedical and Health Informatics
Date/Quarter for which admission is sought:

Personal Information
Family Name: Given Name: Middle Name:

Business Mailing Address:
Line 1:
Line 2:
Line 3:
City: Country: Postal Code:
Business phone Country Code: City Code: Number:
Business FAX Country Code: City Code: Number:

Home Mailing Address:
Line 1:
Line 2:
Line 3:

City: Country: Postal Code:

Home Phone Country Code: City Code: Number:
Home FAX Country Code: City Code: Number:
Sex: Male Female Date of Birth: City of Birth:
Citizenship: Country of Birth:

Examinations Taken:
Please attach a copy of score reports, if available, and arrange to have official score reports sent directly to the University of Washington Graduate Admissions office.
A copy of my GRE score report is attached, and I have requested ETS to send an official score report directly to the University of Washington.
I am registered to take the GRE test on (Month/Day/Year). An official report will be sent directly to the University of Washington.
A copy of my TOEFL score report is attached, and I have requested ETS to send an official score report directly to the University of Washignton.
I am registered to take the TOEFL test on (Month/Day/Year). An official score report will be sent directly to the Univesity of Washington.

Education: (List most recent degree first)
Organization City Country From (Month/Year) To (Month/Year) Degree Received Major

Health Related Experience: (List most recent first)
Organization City Country From (Month/Year) To (Month/Year) Degree Received

References:
Please list names, titles, fax, mailing and e-mail addresses of referrees who have written reference letters for you.
Reference 1 Address:
Address 1:
Address 2:
Address 3:
City: Country: Postal Code:
Email:
FAX:
Reference 2 Address:
Address 1:
Address 2:
Address 3:
City: Country: Postal Code:
Email:
FAX:
Reference 3 Address:
Address 1:
Address 2:
Address 3:
City: Country: Postal Code:
Email:
FAX:

Statement of training objectives and career goals.
Please use a separate sheet to answer the following questions. Be as complete and specific as possible.
a. Describe your professional background.
b. Describe your reasons for seeking admission to this program.
c. How would your participation in this program be useful in furthering your career goals when you return to your country?
Curriculum Vitae.Please attach a current copy of your CV and copies of your recent scientific publications.
I certify that the above information is true to the best of my knowledge.
Today's Date
The University of Washington provides equal opportunity in education without regard to race, color, creed, religion, national origin, sex, sexual orientation, age, marital status, disability, or status as a disabled veteran or Vietnam era veteran in accordance with University policy and applicable federal and state statutes and regulations.
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