Public Works Leadership Academy Registration Form Please fill out the following form to register for the Public Works Leadership Academy Certificate. Personal Information First Name Middle Name Last Name Suffix Specify Address Type Home Work Address 1 Address 2 City State Zip/Postal Code County Personal (Home/Cell) Phone Work Phone Email Current Employer Current Job Title Gender Male Female Date of Birth (Month/Day/Year) Have you taken a class at Hamline before? Yes No If yes, please enter your Hamline ID if known. Are you interested in more information about a Master of Public Administration degree from Hamline? Yes, I am interested. No, I am not interested. How did you hear about this program? (Select) Catalog Email Website Friend Supervisor Community Board Other If other is selected, please specify. Verification Please type your full name: Please type today's Date (day/month/year): By checking the box, you are signing this registration form and agree that doing so is the equivalent of your manual signature. For information about certificate programs, please contact Cynthia Johnson, Non-Degree Programs Coordinator Phone (651) 523-2962, Email firstname.lastname@example.org For billing questions, please contact Hamline Student Accounts, 651-523-3000.