HEALTH CARE APPLICATION APPLICATION FOR ADMISSION Health Care Management Program You must fill in a name, address, and phone number. Name: Email: Nickname (for name card): Home Address Street: City: State: Zip: Phone: Organization Name Street: City: State: Zip: All material will be sent to the home address unless you prefer otherwise: Please send to my company address Please do not send to my company address Educational Background: Recent Courses or Seminars: Have you taken a course utilizing the Case Method? Areas of Work Experience: (Check all that apply) Finance Purchasing Engineering/Maintenance Nursing Human Resources Operations/Service Counseling Intake Sales/Marketing Pharmacy Surgical Medical Research Diagnostic Quality/Safety Control EDP/Data Management Other Current Job Title: Do you supervise others?: Yes No How did you learn of the Management Development Program? Friend/Colleague Hospital Posting Prior Students Moderator Buffalo-Niagara Medical Campus news letter[We KNow] Other: