2019 License & Certification (L&C) Application
Before submitting this application, please see the FAQs at http://www.seiu-uhweduc.org/skills-development/license-certification-exams/.

Please submit all reimbursement documents within 10 business days after receiving the confirmation email.

NOTE: Submission of this form is the first step in the reimbursement process.

First Name *
Your answer
Middle Name
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Last Name *
Your answer
Street Address *
Your answer
Apartment or Unit Number
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City *
Your answer
State *
Zip Code *
Your answer
Gender *
Ethnicity *
Birthdate *
MM
/
DD
/
YYYY
Email Address *
Primary means of contact so please check regularly
Your answer
Secondary Email Address
Your answer
Cellular Telephone *
Your answer
Work Telephone *
Your answer
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