Certificate in Chinese Herbal Medicine - Application for Admission Please fill out all fields. Once your completed application materials have been received, you will be notified of the status of your application and interviews with members of the Admissions Committee will be scheduled. Personal InformationApplicant Name* (last, first, middle)Date of Birth*Social Security #*Phone*Email* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code In case of emergency, notify:Name:* Relationship:*Phone*Email* Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Ethnic Information (for statistical purposes only)* White/Non-Hispanic African-American/Black Hispanic/Latino Asian Native American/Alaskan Native Hawaiian/Pacific Islander Two or more races Ethnicity Unknown Prefer not to answer I am a Licensed Acupuncturist License NumberStateYear of LicensureI am an NCCAOM Diplomate Year of CertificationPlease list all colleges/universities classes, beginning with the most recent.Name of Institution*(no abbreviations)Location*(city, state)Degree(s) Sought*Date Started* Date Finished* If no degree was awarded, please indicate the approximate number of credits earnedName of Institution(no abbreviations)Location*(city, state)Degree(s) SoughtDate Started Date Finished If no degree was awarded, please indicate the approximate number of credits earned Add Another Name of Institution(no abbreviations)Location(city, state)Degree(s) SoughtDate Started Date Finished If no degree was awarded, please indicate the approximate number of credits earnedHow did you hear about the Certificate in Chinese Herbal Medicine program?* DT Student DT Clinic Acupuncturist/Health Professional CEU Classes Print Ad or Mailing Local Awareness Daoist Traditions' Website Specific Website(s) Other Please list the websites you heard about us from:*Please write where you heard about us:*Have you ever had a license, certificate, or credential revoked or suspended?*YesNoPlease explain the circumstances*Have you ever been convicted of a felony?*YesNoPlease explain the circumstances*AttachmentsPassport Style Photo*Accepted file types: gif, png, pdf, jpg.Please submit a current, full face passport style photo in .jpg, .png, .gif, or .pdf formatCopy of valid photo identification (driver's license preferred)*Accepted file types: jpg, gif, png, pdf.Accepted image types: .jpg .png .gif .pdfResume (optional)Accepted file types: docx, pdf, doc.Immunization RecordsAccepted file types: pdf.Upload your completed Immunization Records form here, or skip if you plan to email it later.In accordance with North Carolina State law (G.S. 130A-152) all students must submit documentation of required immunizations within 30 days of the start of classes. If you have your current immunization records, the form can be uploaded along with your application or it can be emailed separately to email@example.com at a later date. Click here to download the Immunization Record Form with instructions. Non-Digital SubmissionsLetter of reference from a professional contact, ie: employer/teacher, mailed directly to Daoist Traditions.* I waive my right to access/view this letter of reference. Letter of Reference must be mailed directly to the college at 382 Montford Ave, Asheville NC 28801 or emailed to firstname.lastname@example.org .Official college transcripts mailed directly to Daoist Traditions from the institution.Official College Transcripts showing 60 semester credits/90 quarter units of general education at the baccalaureate level from a college/university accredited by an agency recognized by the U.S. Secretary of Education. Must be mailed directly to Daoist Traditions from the Institution or official electronic transcripts emailed to email@example.com from the Institution.ConfirmationBy checking this box you certify that all information provided is accurate and complete. Any misrepresentation may be grounds for dismissal.* I certify and agree. Our Admissions Coordinator will contact you to schedule your interviews with members of the Admissions Committee once your completed application materials are received. Thank you for your interest in Daoist Traditions.Application Fee* Price: $ 75.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name This iframe contains the logic required to handle AJAX powered Gravity Forms.