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General Information

Date:

7/29/2010

* Applying for Year:

Domestic Student

International Student

Transfer Student

Spring Semester

Fall Semester

Contact Information
* First Name:
Middle Name:
* Last Name:
Other Name Used (Maiden):
* Date of Birth (mm/dd/yyyy):
* Gender:
* Social Security Number:
* Permanent Address:
* City, State, Zip:
Mailing Address (if different from Permanent Address:
City, State, Zip:
Home Phone:
Business Phone:
Mobile Phone:
Fax:
Email Address:
Emergency Contact Name:
Relationship:
Mobile Phone:
Day Phone:
Evening Phone:
Email Address:

Citizenship Information
Place of Birth (City/State, Country):
Country of Citizenship:
Visa Type (Permanent Resident and Non-U.S. Citizens):
Visa Number:
I will apply for a Student Visa (F-1) I will apply for an Exchange Visitor Visa (J-1)

Academic Information

Previous University #1
College or University
Location
Major
Degree Earned
Year Earned
Dates Attended
Credits Earned, GPA	,
Previous University #2
College or University
Location
Major
Degree Earned
Year Earned
Dates Attended
Credits Earned, GPA	,
Previous University #3
College or University
Location
Major
Degree Earned
Year Earned
Dates Attended
Credits Earned, GPA	,
Previous University #4
College or University
Location
Major
Degree Earned
Year Earned
Dates Attended
Credits Earned, GPA	,

Personal Information

Do you have any special needs that we should be aware of? if so, please describe:

Have you ever been convicted of a felony or misdemeanor other than a traffic vialation? if so, please describe:

Have you ever had a professional credential or license revoked or suspended? if so, please describe:

Do you plan to apply for Financial Aid?

Yes

How did you find out about Florida College of Integrative Medicine?

Which individual was instrumental in helping make your decision to attend FCIM?

Please affirm the following statement by entering your name and today's date below as a digital signature:
"I certify that all statements and information provided on this application are correct and complete."

* Signed: * Date: