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Name ___________________________________ Maiden ______________
Address ______________________________________________________
City ____________________________________ State _____ Zip ________
Telephone: work _____________ Home ____________ Cell ____________
Date of Birth __________ Age __________ Social Security # ____________
Educational Status: Highest Grade Completed 12 13 14 15 16 17 18
HS Attended _______________________________ Date Graduated ______
College Attended ___________________________ Date Graduated ______
Degree/Major ___________________________________________________
Technical School ________________________________________________
Military Service/Training __________________________________________
Program you are applying for ______________________________________
Are you applying for Advanced Standing? _____ Yes _____ No
Do you currently hold any health care licensures? _____ Yes _____ No
Have you had your license revoked/suspended? _____ Yes _____ No
Have you ever been convicted of a felony? _____ Yes _____ No
(If Yes to A, B, or C, please attach an explanation)
WORK EXPERIENCE
List work experience for the past five (5) years beginning with the most recent and describe all responsibilities, including why you changed jobs.
1._____________________________________________________________
_______________________________________________________________
2.______________________________________________________________
_______________________________________________________________
3.______________________________________________________________
_______________________________________________________________
State briefly why you feel you will succeed as a Natural Therapies Practitioner.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
The International Academy of Naturopathy does not discriminate on the basis of race, color, nationality or ethnic origin in the administration of its educational policies, admissions policies or scholarship and loan programs.
I CERTIFY THAT ALL THE ABOVE INFORMAITON IS ACCURATE, CORRECT AND TRUE:
SIGNATURE __________________________________ Date ___________
Enclosed is my check for the Application Fee (non-refundable) of $100 US.
MAIL TO ADDRESS BELOW
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