Form 08-4215d - Course Of Study Certification Page 10
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10SUBJECT
RESOURCE(S)
(6)
Various sites, styles, and modes of practice within midwifery.
As the applicant, I certify that the information provided on this course of study certification is true and correct to the best of my knowledge.
Printed Name of Applicant
Signature of Applicant
Date
As the preceptor, I certify that the information provided on this course of study certification is true and correct to the best of my knowledge.
Printed Name of Preceptor
Signature of Preceptor
Date
SUBSCRIBED AND SWORN TO before me, a notary public in and for the State of
, this
day of
19
.
NOTARY SEAL
Notary Public
My Commission Expires:
08-4215d (Rev. 11/99)
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