	Canadian Therapeutic College
Acupuncture	Application Form

Date of Application:

Enrolment Date:

I. Personal Information

Name:
	SURNAME		FIRST NAME

Address:

City:

Postal Code:

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Telephone:

Date of Birth:

Gender:

E-mail address:

Languages:

Spoken:

English

French

Other:

Written:

English

French

Other:

II. Medical History

In order to be accepted by Canadian Therapeutic College, you must attach or have forwarded our entry

immunization form (provided by the College) indicating good health, freedom from all communicable

diseases and an up-to-date immunization and T.B test (if the T.B test is positive a yearly chest x-ray is

required as well as follow up treatment.)

III. Academic Education Training

Secondary School:

City:

Completed Grade:

From:

To:

Post Secondary

Institute:

Degree

Diploma:

From:

To:

Certification/License:

Attach copies of diplomas, degrees, certificates, health care license and transcripts

________________________________________________________________________________________

Canadian Therapeutic College

Mail to: 760 Brant Street Burlington, ON. L7R 4B7 or Fax to: 905-632-2895

Telephone: 905-632-3200 or 1-877-278-8888

www.canadiantherapeuticcollege.com

	Canadian Therapeutic College
Acupuncture	Application Form

IV. Motivation for Application

Attach a statement outlining your motivation for applying to this program.

V. Character References

Please indicated two original reference letters of your good character from non-family members, who have

known you for more than two years. Letters must be signed, dated and include the individuals address and

phone number.

Name:

Address:

Occupation:

Telephone:

Years Known:

Name:

Address:

Occupation:

Telephone:

Years Known:

VI. Please check the following:

( ) Academic transcripts (diploma, degree, certification) forward directly to the College from the Institution

( ) Current (written) criminal background check from the applicant’s local Police Department

( ) Standard First Aid and Level C CPR

( ) Entry Immunization Form

( ) Two character references

( ) Statement of motivation

( ) Proof of health care professional status

( ) Proof of length of time as health care professional (minimum requirement is 2 years)

( ) Application fee $75

I agree to allow Canadian Therapeutic College collecting the personal information about me in this

document in order to provide the services requested. I understand that the information is protected and

treated confidentially and that I have the right to review it.

Signature of applicant:

_______________________________________________________________________________________

Canadian Therapeutic College

Mail to: 760 Brant Street Burlington, ON. L7R 4B7 or Fax to: 905-632-2895

Telephone: 905-632-3200 or 1-877-278-8888