901 N. Washington Avenue Lansing, Michigan 48906-5137 Telephone: (517) 485-5484 FAX: (517) 485-0801 E-Mail: saem@saem.org

Please fill out form completely and submit to SAEM, 901 North Washington Avenue, Lansing, MI 48906.
Forms must be typed. SAEM is not responsible for typographical errors due to hand written submissions.

Information to appear on certificate:

MEDICAL SCHOOL: _____________________________________________________

2006 MEDICAL STUDENT WINNER: _______________________________________

DATE TO APPEAR ON CERTIFICATE: ______________________________________

Information needed for subscriptions:

Student Mailing Address: __________________________________________________

______________________________________________________________________

Phone: ________________________________________________

If you need the certificate for a senior awards ceremony, please fill in the date needed:
(Due to mailing time, please send information four weeks prior to the date needed).
_______________

Certificate to be mailed to: (Certificate will be mailed via regular US mail. Requests for overnight delivery
will be accomodated, but the expense is the responsibility of the institution.)

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Contact Phone: ________________________________________________

Dean or Designee (Please Print) ___________________________________________

Dean or Designee Signature _______________________________________________

Course Coordinator (Please Print) ___________________________________________

Course Coordinator Signature ______________________________________________

Address of Coordinator: ___________________________________________________

_________________________________________________________________

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