APPLICATION FOR ADMISSION
Please type in and print this form

 
PERSONAL DATA
 
Last Name: Last First Middle:
Other Names:
   
Social Security Number:
   
Sex: Female Male
   
Mailing Address: Street: City:
State: Zip Code: Country:
   
Permanent Address: Street: City:
State: Zip Code: Country:
   
Home Phone: ( )
   
Work Phone: ( )
   
Mobile/Pager: ( )
   
Email:
   
Date of Birth: Month: Day: Year:
   
Place of Birth:
   

CITIZENSHIP

 
United States: Native: Nationalized:
Other (country name): Type of visa: Date issued:
US Permanent Resident Visa. Green Card Number Citizen of
Please attach a front-and-back copy of your current green card or visa.
 

APPLYING FOR

Fall Spring Summer Year 20

Full-Time (12+units) Part-Time (1-11 units)

Degree program Non-degree program o Audit

New Student Transfer Student
DO YOU EXPECT TO TRANSFER ANY PREVIOUS TCM CREDITS INTO THIS PROGRAM? Yes No

Official transcripts must be mailed directly to UEWM from your previous colleges. Any transcripts with a broken seal will be unofficial and will not be accepted.Traditional Chinese Medicine and Acupuncture
 

COURSE INSTRUCTION LANGUAGE PREFERENCE

 
English Chinese English/Chinese
 
PREVIOUS TRAINING
 

Acupuncture Massage Chinese Chinese Herbal Medicine Taiji/Qigong

 
EDUCATIONAL BACKGROUND

Please list the names of all post-secondary institutions you have attended In order to be granted transfer credits, you must submit an official transcript in a sealed envelope. Any documents from foreign countries must be evaluated by an evaluation agency.

Name and Address of University and Colleges Attended
Date attend/units completed
Major/Degree
 
WORK EXPERIENCE (Please include a resume and provide an overview here.)
       
Name of Company
From
To
Your Position/Duties
IN CASE OF EMERGENCY, NOTIFY

Name: Relationship: Phone :
Address :

 
ETHNIC BACK GROUND (Information in this section will be used for statistical analysis only and is strictly voluntary)

African American/Black American Indian/Alaskan Native Asian/Pacific Islander
Hispanic/Latino(a) Mexican/Mexican-American/Chicano(a) White/Caucasian Other

 
CERTIFICATION

Your signature certifies the accuracy and completeness of the information provided and the truth of the following certification. This application must be certified before processing.

I certify that I have provided complete and accurate statements on this application. I understand that failure to list all colleges attended or the falsifying of official documents may result in denial of admission or disciplinary action. I understand all official documents submitted in support of this application become the property of the University. I authorize the release of any information submitted by me in connection with this application to any person, firm, corporation, association, or government agency, but only to verify or explain the information. I understand that acceptance as a student requires submission of official college transcript(s).If not received by UEWM prior to my initial registration; full admission is pending receipt of the documents. Grades and transcripts of credits will be withheld, and registration for subsequent terms may be denied until this requirement is met.

 

Applicant's Signature Date