Medical Acupuncture @Downstate Registration Please complete all the information requested. Question Title * 1. Demographic Name: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: Phone Number: Question Title * 2. Gender: Male Female Question Title * 3. Medical School attended- Name State Country, if not USA Dates of Attendance Graduation Date (month/year) Question Title * 4. Current Employer/City/State Question Title * 5. Position/ Years employed Question Title * 6. Select one or more of the following five groups: American Indian or Alaskan Native Asian Native Hawaiian or other Pacific Islander Black or African American White Question Title * 7. What is your motivation for choosing this program? What do you hope to gain from this curriculum? Question Title * 8. Tuition for the entire certificate program is $5,500. You may register for each section individually ($1900 per section). For payment arrangements please contact the Office of CME at 718-270-2422. Fee does not include books and required materials such as needles. Full Program, $5,500 Full Program. $5,000 – SUNY physicians Section I - $1,900 Section II - $1,900 Section III - $1, 900 March Session 0 September Session 0 Other (please specify) To pay by credit card, download the Payment Form. Question Title * 9. Which session are you applying for Spring Session (starts in March or April) Fall Session ( starts in Sept. or October) I hereby certify that all the information given in this application is accurate and complete. I understand that all the information contained in this application will be treated confidentially and will be used for institutional purposes only. I realize that failure to provide complete and accurate information may affect my admission. I understand that my application will not be considered until all necessary documents are received by the Office of Admissions. ___________________________________________________________ _____________________ Question Title * 10. Signature of Applicant Name: Question Title * 11. Date Date Date Done