Please type or print legibly in black ink.
Be sure to sign and date this form.
_{For best results in printing this form, please set font (type) size in
Netscape 'preferences' or Internet Explorer 'options' to 'smallest' or '10 pt.'}

Fax your form to: International College of Traditional Chinese Medicine of Vancouver (604) 731-2964

Mail your form to: International College of Traditional Chinese Medicine of Vancouver Suite 201, 1508 W. Broadway, Vancouver, B.C. Canada V6J 1W8

1. Full Name:
 _{(Last name)} ______________________ _{(First name)} _________________
 _{(Middle name)} ________

2. Permanent Address: _______________________City _____________

_{(Postal Code)} _________ _(Country) ______________________

 Mailing Address if different: ______________________City _____________

_{(Postal Code)} _________ _(Country) ______________________

3. Telephone Number: _(Home) __________________ _(Work) __________________

(e-mail address) __________________________________

4. Please provide a contact name and telephone number in case of emergency:

Name_________________________ _(Phone) _____________ _{(Relationship)} ___________

5. Please Circle:  Canadian Citizen    Yes   No
                            Resident                 Yes  No

If not Canadian please  indicate citizenship and residence: ___________________ | ___________________

                                                                                      
6. Please list in chronological order your post-secondary educational history:

Institution	Date attended (mo/yr)	Degree and Date	Major field of study

(Please attach additional sheet if necessary)

7. Please list in chronological order your work history in the past three years:

Name of Company	Position & Type of Work	Inclusive Dates

8. Applying for: Full-time study _____ Part-time study _____

  Diploma Program _____  

        Diploma Program Choice:

        Doctor of TCM ___    TCM Practitioner ___   Acupuncturist ___ Herbalist ___

        Course in English ___       Course in Mandarin ___

        Full-time study ___     In Grade ______

       Part-time study ___       Courses _________________________________________

       ___________________________________________________

        

   Certificate Program ___

   Medical Acupuncture ___ Medical Horology ___

        Certificate Choice:

          Course in English ___       Course in Mandarin ___

          Full-time study ___ 

          Part-time study ___  Courses __________________________________________  

______________________________________________________

10. Beginning term - indicate when you plan to begin studies at

      ICTCMV:  Sep. to Apr. _____ Jan. to Apr. _____ May to Aug. _____

11. Please indicate how you will pay for the tuition and other costs:

     Self-supporting _____ Student loan _____

     Others; please specify: _____________________________________________________________

12. How were you referred to the college?: _________________________________________________

13. Please attach an essay of no less than 500 words, stating in detail your personal reasons for
wanting to enroll in this course, and your vision of your future career goal(s) in the field of TCM.

The following materials must be submitted to the office of admissions in connection with this application:

• A non-refundable application fee of $100.00 ($20.00 for Continuing Education Program) must be received before any admission process can begin.
• This application must be completed in full with your signature.
• Complete official transcripts (sent directly to the College from the institution(s) you have attended.).
• Transfer credit fee of 100.00 per course you wish to apply credit for.  For course credits that are denied, you will be given a full refunded and only charged for the course credits approved.
• Canadian resident students holding or requiring a visa must attach a copy of the valid visa. Foreign students must attach a copy of a valid passport and valid visa.
• Payment can be made by Cash, Debit Card, Bank Draft, or Certified Check (payable to ICTCM of Vancouver).

This application must be completed in full.
Please make a photocopy for your own records and forward the original to the College.

I CERTIFY THE ABOVE INFORMATION IS ACCURATE AND TRUE, AND
I AGREE TO THE TERMS AND CONDITIONS STATED IN THIS APPLICATION.

Signature ________________________________ Date ___________

_{For Office Use Only
Application fee paid: Yes ___ No ___ By __________ Date ___________
Part-time ___ Full-time ___ Date Notified __________________________}