Application Form

This application is for Initial Exam takers only. If you need to retake a section or sections of the exam, please download the Retake Exam form and send it in with a signed Proctor Agreement.

Clicking the blue tabs will open the separate sections to fill out. Please enter as much information as you have in all these sections.

Which Exams Are You Applying For (check any that apply):

Personal Information

(complete ONLY if not USA)


i.e. call before sending FAX

Summary of Homeopathic Training:

#1 Program Name: Hours:

#2 Program Name: Hours:

#3 Program Name: Hours:

Other Programs - (Total for all others) Hours:

Seminars & Conferences - (Total for all of them) Hours:

TOTAL HOURS:

Supervised Clinical Experience (Apprenticeship):
(use mm/dd/yyyy format for dates)

From: To: Contact Hours: Avg. Pts/week-New: Follow-up:

Supervisor(s):

From: To: Contact Hours: Avg. Pts/week-New: Follow-up:

Supervisor(s):

Practice Experience:

Beginning Date: Approx.Tot # of new patients seen:

Current: Average # of New Patients/Week: Percent of practice that is homeopathic %

Average length of initial visit for a patient with a chronic complaint (NUMBER of hours):

Types of cases commonly seen: (240 Characters - MAX) (use tenths for partial hours, e.g.1.5) Other Qualifying Training or Experience:(240 Characters - MAX)

Health Sciences Training or degrees (240 Characters - MAX) : Includes: anatomy, physiology, pathology
CPR Training (Organization and Date) (240 Characters - MAX) :

NOTE:If this form is submitted by mail, FAX, etc., instead of electronically,an additional fee
must be included with the application.

Please enter the code to the right of the text box.