APPLICATION FORM
EDUCATIONAL PROGRAM IN NATURAL MEDICINE PROGRAM
Please either copy/paste into your email or print this page and fill out the following information, then email or fax it to:
panamint@caribsurf.com tel. (869) 469-9490
Name and Contact info
NAME:__________________________________________ DATE:___/___/06
ADDRESS:____________________________________________
CITY:______________________ST/PROV.___________________CODE:___________
COUNTRY:_____________________ email address:________________@_______________.com
Fax no.____(_______)_________________________
Personal WWW Homepage:http://_____________________________________
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___ Diploma Program in Natural medicine (PNM)
___ Doctorate Progaram in Natural Medicine (DNM)
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Personal info
Exact Birthplace:
Birthdate and exact time (if known):
Citizenship Status:
Marital Status:
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Educational/Professional info
We accept all credentialed and qualified doctors (any kind), nurses, counselors, bodyworkers and other therapists and wholistic practitioners.
Undergraduate Institution:
Degree Awarded/Field: Date:__________________Graduated:
Graduate Institution:
Degree Awarded/Field: Date:________________Postgraduated: Specialty:
Current Practice Facility: Private?:
Specialties:
How long working there?:
Published Papers:
Current occupation if not in practice:
Years of experience in the health field:
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Interest info
Prof. Major Interests:
Prof. Minor Interests:
Personal Interests:
Anything else you'd like to volunteer to tell us about yourself?
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Goals info
Are you interested in a (check one) ____4 week internships? ___Two, 2 week internships within 1 year?
Finally, in the following section, please check the methodologies you might also be interested in studying with us, and (in the space to the right) give a brief explanation of your reasons for wanting to study that method particular method.
__Nutritional chemistry __Herbology:
__Electroacupuncture diagnosis ___ Laboratory medicine
__Lymphatic Drainage: __Jade Bodywork:
Other topics you might be interested in?
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Thank you for your time! Also e-mail a recent "passport
style" photo (jpg, tiff, pict, gif) of yourself. We will
be in contact with you shortly.
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Acceptance into a formal program requires a personal interview, please contact Dr. Charles for a scheduled appointment by e-mail at panamint@caribsurf.com
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For room reservations on campus, call or fax (869) 469-9490
Dear Candidate:
Print out this section and choose two (2) individuals (professionals) that can support your application into the program. Have the individuals post or fax their responses to the school.
REQUEST FOR CHARACTER REFERENCE No. 1
PanAmerican School of Natural Medicine, POB 553, Charlestown, NEVIS, West Indies; fax (869) 469 9490; www.panaminstitute.com
_________________________________________ is a candidate for admission to PSNM. The candidate respectfully requests we contact you to supply a recommendation in support of admission into a Doctor of Natural Medicine program. Kindly fill out the following scale by marking a number - 1, 2, 3, or 4, that best describes the candidate, based on your genuine contact with the applicant. Rate the candidate relative to others with whom you have been associated in the same or similar capacity.
Scale: 1. Outstanding; 2. Satisfactory; 3. Poor; 4. No chance to observe or judge
| Assessment | 1. Outstanding | 2. Satisfactory | 3. Poor | 4. No chance to observe |
| 1. Scholarship | ||||
| 2. Integrity | ||||
| 3. Thoroughness of preparation | ||||
| 4, Initiative | ||||
| 5. Leadership | ||||
| 6. Appearance/dress | ||||
| 7. Poise and self control | ||||
| 8. Sense of responsibility | ||||
| 9. Tact, Diplomacy | ||||
| 10. Decision making ability | ||||
| 11. Written Communication skills | ||||
| 12, Oral Communication Skills |
Comments:
Name of Assessor___________________________________ Title:_________________________
Business Name______________________________________________________
contact: (_______) ____________________ Fax (_______) _______________________
email address:____________________________________________
Signature:_________________________________ Date: _____/_____/0___
REQUEST FOR CHARACTER REFERENCE No. 2
PanAmerican School of Natural Medicine, POB 553, Charlestown, NEVIS, West Indies; fax (869) 469 9490; www.panaminstitute.com
_________________________________________ is a candidate for admission to PSNM. The candidate respectfully requests we contact you to supply a recommendation in support of admission into a Doctor of Natural Medicine program. Kindly fill out the following scale by marking a number - 1, 2, 3, or 4, that best describes the candidate, based on your genuine contact with the applicant. Rate the candidate relative to others with whom you have been associated in the same or similar capacity.
Scale: 1. Outstanding; 2. Satisfactory; 3. Poor; 4. No chance to observe or judge
| Assessment | 1. Outstanding | 2. Satisfactory | 3. Poor | 4. No chance to observe |
| 1. Scholarship | ||||
| 2. Integrity | ||||
| 3. Thoroughness of preparation | ||||
| 4, Initiative | ||||
| 5. Leadership | ||||
| 6. Appearance/dress | ||||
| 7. Poise and self control | ||||
| 8. Sense of responsibility | ||||
| 9. Tact, Diplomacy | ||||
| 10. Decision making ability | ||||
| 11. Written Communication skills | ||||
| 12, Oral Communication Skills |
Comments:
Name of Assessor___________________________________ Title:_________________________
Business Name______________________________________________________
contact: (_______) ____________________ Fax (_______) _______________________
email address:____________________________________________
Signature:_________________________________ Date: _____/_____/0___