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Application for Admission

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Applicant Information

First name

Middle name

Last name

Preferred name

Date of Birth

Social Security #

Mailing Address (for school correspondence)

Address

Phone

Undergraduate Education

College/University

Degree(s)

Dates Attended

If no degree was awarded, please indicate the approx. number of credits earned

College/University (second)

Degree(s)

Dates Attended

If no degree was awarded, please indicate the approx. number of credits earned

Acupuncture and Chinese Medicine Education (if applicable)

College/University

Degree(s)

Graduation Date

Present Occupation

Are you currently practicing Chinese medicine?

Yes

Practice Name and Location

Present occupation

Relevant Community Service Experience or Extracurricular Activities