New APPLICATION FOR ADMISSION

APPLICATION FOR ADMISSION

Application Date

Anticipated Start Date

Program

*Re-Enroll Students

If you are re-enrolling to PIHMA, please do not complete an online application. Contact your admissions representative and they will send you the correct application.

Personal Information

First name

Last Name

Middle Name

Former Name

Birth Date

Gender

Social Security No

Home Phone

Cell Phone

Mailing Address

Street

City

Emergency Contact

State/Province

Zip/Postcode

Country

Contact Name

Relationship

Cell Phone

Where Did You Hear About PIHMA?

Citizenship

If other, Nationality

Type Visa (if not U.S. Citizen)

Student (F-1)

Permanent Resident

Other

Military Status

Cultural/Ethnic Background

(Optional Information)

Ethnicity

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How do you plan to finance your education?

Have you ever been convicted of, pled guilty or no contest to, or forfeited bail for, any criminal conduct under law or ordinance, excluding minor traffic violations

Yes No Not Selected

If yes, please explain in details

Please list volunteer activities, groups, clubs, etc.

Describe your current career or profession:

Briefly describe any experience or training in acupuncture, herbology, Qi Gong, massage, or martial arts:

Education

List all colleges, universities or trade schools you have attended or are currently enrolled in:(Arrange to have official transcripts from accredited academic institutions that you have attended mailed directly to the Admissions office at PIHMA.)

Highest Level of Education

Institution 1

Dates Attended

Degrees/Certificates

Major

Institution 2

Dates Attended

Degrees/Certificates

Major

Institution 3

Dates Attended

Degrees/Certificates

Major

Institution 4

Dates Attended

Degrees/Certificates

Major

Prerequisites and Corequisites

PIHMA requires the following prerequisites and co-requisites: Biology (3 credits, co-requisite), Chemistry (3 credits, co-requisite), Psychology (3 credits, prerequisite), English (3 credits, prerequisite), Organic Chemistry (3 credits, co-requisite) . Have you taken the following?

English

Yes No Not Selected

College Attended for English

English Course(s) Title and Number

English Year Taken

Psychology

Yes No Not Selected

College Attended for Psychology

Psychology Course(s) Title and Number

Psychology Year Taken

Biology

Yes No Not Selected

College Attended for Biology

Biology Course(s) Title and Number

Biology Year Taken

Chemistry

Yes No Not Selected

College Attended for Chemistry

Chemistry Course(s) Title and Number

Chemistry Year Taken

Organic Chemistry

Yes No Not Selected

College Attended for Organic Chemistry

Organic Chemistry Course(s) Title and Number

Organic Chemistry Year Taken

List any awards, honors, scholarships or prizes awarded to you for academic achievement

Please list volunteer activities, groups, clubs, positions of leadership in which you have been involved:

Official Transcripts

You will need to submit your official transcripts before we can accept you as a student. Please have them mailed to: PIHMA Registrar 301 E. Bethany Home Road, Suite A-100 Phoenix, AZ 85012 Electronic records can be emailed to jdrayer@pihma.edu.

Resume Attachment

Unofficial Transcript Attachment

Unofficial

Essay Guidelines

PIHMA requires a short 400-word essay to submit your application. Please do not stress about the essay. It will not affect your acceptance. For information on your essay topics, please visit pihma.edu/online-application/ and scroll down to the Essay Requirements section.

Essay Attachment

Letter of Recommendations

Please provide the name and email addresses of the two people who will be completing the letter of recommendations on your behalf. PIHMA will reach out to them directly to complete the letter of recommendation.

1st Letter of Recommendation Name

Full Name

1st Letter of Recommendation email

email address

2nd Letter of Recommendation Name

Full Name

2nd Letter of Recommendation email

email address

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Signature of the Applicant

Date

I hereby affirm that the foregoing information and submitted attachments are true and accurate to the best of my knowledge. I understand that any misrepresentation or falsification, including failure to report any college or university attendance, is sufficient cause for denial of admission and cancellation of enrollment and/or any credits earned. I further understand that all application materials submitted will be the property of PIHMA and cannot be returned. This information may be reproduced for use during my interview cycle.

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