Name ______________________________________________ Male ____ Female ____

Address ___________________________________________________________________

____________________________________________________________________________

Home phone ______________________ Work phone ________________________

Date of birth _________  Place of birth __________________

Country of citizenship ___________ Social security number _____________

Checkmark your choice:

Status: Full-time _____ Part-time _____ Non-diploma student _____

Starting: Winter 2003 _____ Summer 2003 _____ Fall 2003_____

Starting: Winter 2004 _____ Summer 2004 _____ Fall 2004 _____

List all educational institutions that you have attended since high school in chronological order
 

INSTITUTION	DATES ATTENDED	DEGREE AND DATE	MAJOR FIELD OF STUDY

 
 
 

List honors, prizes or scholarships previously awarded to you on the basis of academic achievement. Also list special skills, licenses and accomplishments.

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

List publications (articles, books and research papers).

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Employment history. Please list in chronological order the jobs you have held in the past five years.
 

EMPLOYER NAME	POSITION AND TYPE OF EMPLOYMENT	DATES

What is your current occupation?  __________________________________________________

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?  Yes _____  No _____

If yes, please explain. ____________________________________________________________

Letters of recommendation. Please list the names and addresses of two persons you are asking to send letters of recommendation.  These letters should be sent directly to AAAOM.
 

NAME	ADDRESS	POSITION	PHONE NUMBER

 
 
 

Personal statement.  Please write a five hundred word essay (on a separate sheet) about yourself and why you want to attend AAAOM.

List your hobbies and interests.

___________________________________________________________________________________________

___________________________________________________________________________________________

How were you referred to AAAOM?

___________________________________________________________________________________________

I hereby certify that the information given by me in this application is true and correct.
 
 

Signature __________________________________  Date _________________
 
 
 
 
 
 
 

Mail this application form  to The American Academy of Acupuncture and Oriental Medicine, Attn: Registrar, 1925 West County Road B2, Roseville, MN 55113. Be sure to enclose the following:  A letter stating your personal educational and professional goals, with your reasons for wishing to attend AAAOM. Official transcripts from all post-secondary institutions (sent directly to AAAOM from the institutions). Two letters of recommendation. $50 application fee.  BACK