APPLICATION for ADMISSION (Please type or print)

 

All information is confidential.

Please complete and return to the Academy.  All application materials are the property of the Acupuncture Academy, and cannot be returned to the applicant. In Academy, there are no limitations, no barriers of race, color, gender, age, religion, national or ethnic origin, family status or sexual preference.

 

1.   PERSONAL INFORMATION

Name: (Last) _____________________ (First)_______________  (  ) Male, (  ) Female

Social Security No.:  ___- __- ___  Date of Birth: __/ __/___  Place of Birth: _________

Home Phone:  (    ) __________ Work Phone:  (    ) _________ Web/Email: _________/ _______

 

Mailing Address:

_______________________________________________________

Permanent Address:

_____________________________________________________

Citizenship:  ___  US Citizen;  ___  Permanent Resident;  ___  Foreign Student

Alien Registration No.:  _____________________;    I-94 No.: ___________________

Program & Entry Status  (Please check one):

Full-time _____;  Part-time _____;  English Program    _____;  Chinese Program  _____

In case of Emergency, Notify:

Person's Name:  ___________________________  Phone No.: _______________

Address:

_______________________________________________________________

Have you ever had a credential or license revoked or suspended?  (  ) Yes; (  ) No

If yes, please explain:

_____________________________________________________

Have you ever been convicted of a felony?

If yes, please explain:

_____________________________________________________

 

2. REFERENCES

Name            Address            City/State/Zip Code    Phone

1.)  ______________  _______________________  _____________ (   ) _______

 

2.) ______________  _______________________  ________________ (   ) ________

 

3. EDUCATION

 

Name of Institution / State / From-To / Major / Degree or Diploma / Date Received

1.)

_________________________________________________________________

2.)

_________________________________________________________________

3.)

_________________________________________________________________

4.)

_________________________________________________________________

 

4.  WORK EXPERIENCE: Please list all paid employment services beginning

with the most recent

 

 Employer City/State Position From-To Hr./Wk   

1.)  ______________________ ___________ ____________ _______

 

2.)______________________ ___________ ___________________ ________

 

3.)______________________ ___________ ___________________ ________

 

4.)_______________________ ___________ ___________________ _______

 

5. CHECKLIST:

 

* Application Form;

* Non-refundable application Fee;

* Transcripts: All transcripts must be Official and Directly from the institute;

* Bachelor level equivalence with minimum 3.00 GPA;

* Updated Resume;

* Statement of Purpose: write an essay stating why you want to study;

* Two Passport-sized Photographs;

* Two letters of Recommendation;

* Health certificate: Chest X-ray & Blood Tests are required for hepatitis/TB/HIV (AIDS);

*  Medical Insurance proof.

-------------------------------------------------------------------------------------------------------------------------

I understand that all documents presented for admission or evaluation.  It is the property of the Academy and is not returned to the applicant. I certify that all information supplied is true and correct. Otherwise I will be dismissed from the Academy.

 

_______________________ / ___________________________ / ___/___/___  

Applicant Printed Name    Signature     Date