Apply Online — Chicago College of Oriental Medicine

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Program

Which program are you applying for? *

Master of Acupuncture Master of Acupuncture and Chinese Herbal Medicine

Personal Information

Legal First Name *

Legal Middle Name

Legal Last Name *

Address Line 1 *

Address Line 2

City *

State *

Zip *

Country *

Home Phone

Cell Phone *

Email Address *

Is your permanent address the same as your present address? *

Yes No

Permanent Address Line 1

Permanent Address Line 2

City

State

Zip

Country

Home Phone

Cell Phone *

Personal Details

Date of Birth *

Age *

Country of Birth

Sex *

Male Female

Are you a Citizen of the US or of the US Territories? *

Yes No

If No, do you have:

Green Card F-1 or M-1 VISA Need an F-1 or M-1 VISA

Were you enrolled in another US College/School within 5 months of enrollment at CCOM? *

Yes No

Highest level of education completed? *

Emergency Contact

In Case of Emergency, Notify (Name) *

Address Line 1 *

Address Line 2

City *

State *

Zip *

Country *

Phone *

Financial Information

Are you able to completely finance your own education? (tuition, fees, living expenses, transportation, etc.) *

Yes No

If no, would you require a payment plan?

Yes No

Background

Employment and Volunteer Service

Please list all paid employment and/or voluntary service for at least the last three years, beginning with your most recent.

Character References *

Names and addresses of three character references. CCOM will send character reference forms to those persons listed on the application. Those persons should complete the form and return it to the college. Relatives are not accepted as references.

Have you been convicted of a felony? *

Yes No

How did you hear about us? *

Tell us why you would be interested in the field of Acupuncture and Herbal Medicine.

Certification

I hereby make Application for Admission to the Chicago College of Oriental Medicine and certify that all information given on this application is true. An admission representative will contact you soon after you submit this form. If there are any questions regarding the application process, please contact us at 312-368-0900.

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