General Information:

Name:__________________________________________________________ Soc. Sec. #                                                 

Address:_________________________________________________________ City/State_ ___________________/________

Zip:___________________ Phone:(________)_____________________Date of Birth:________________________________

Place of Birth:_________________________________                 Citizenship:______________________________________

Driver's License State/Number:_______________________/____________________________________________________

Emergency Contact: Name_______________________________Address:_________________________________________

Date of Requested Entry: Year_______ February______ August______

Foreign Applicants only:

Indicate VISA currently held:_________________________

Will you apply for a student VISA?____________________

List in chronological order colleges and universities attended:

Institution                                 Dates Attended            Degree and Date                 Major

1)__________________________________________________________________________________________________

2)__________________________________________________________________________________________________

3)__________________________________________________________________________________________________

4)__________________________________________________________________________________________________

List any honors or scholarships based on academic achievement:

1)__________________________________________________ 2)_____________________________________________

3)__________________________________________________ 4)_____________________________________________

5)__________________________________________________ 6)_____________________________________________

Have you ever had a license revoked or suspended? Yes:______ No:______

If yes, please explain circumstances:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Have you ever been convicted of a felony? Yes:______ No:______

If yes, please explain circumstances:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Optional Information:

Current Occupation:_________________________________________________________________________________

How did you learn about the College:__________________________________________________________________

__________________________________________________________________________________________________

 This application must be completed in full; resumes may not be substituted.

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

1) A non-refundable application fee of $75.00 payable to the Texas College of Traditional Chinese

Medicine. ($500.00 application fee for foreign students).

2) Complete official transcripts documenting all previous college work. Transcripts must be mailed directly to the College from the institution where the work was completed. Foreign students must provide English translation of college documents.

3) 1 full front passport size photograph.

4) Photo copy of a current driver's license. Foreign students may provide copy of photo page of passport.

5) A personal letter explaining your interest in Oriental medicine and your reasons for wanting to attend the Oriental medicine program at the College.

I certify the information contained in this application and in all supporting documentation to be true.

Signature:_______________________________________________________________ Date:__________________