Health Care Naturally, The Future is Ours Permanent Mailing Address Citizenship U.S. Othe.pdfVIP

Name: ____________________________________________________________________________________________________ Last First Middle Social Security Number: ____________________Planned Enrollment Date:_____________________________________________ Sex: ? Male ? Female Date of Birth:_______/_______/_______ Place of Birth ____________________________________ List any other names that may appear on your transcripts / records (i.e. birth name):______________________________________ Citizenship: ? U.S. ? Other (Specify Country) __________________________________________________________________ Type of Visa (if not U.S. Citizen): ? Student (F-1) ? Exchange Visitor (J-1) ? Permanent Resident (Immigrant U.S.) ? Other (please specify): __________________________________________________________________________________________________________ Emergency Contact Name:______________________________________ Relationship:_______________ Phone:_______________ Emergency Contact Address: __________________________________________________________________________________ Present Mailing Address: Street City, State, Zip Telephone (day) Telephone (evening) Email Address: Permanent Mailing Address: Street City, State, Zip Telephone (day) Telephone (evening) AINM Doctoral Application RD 082502a— 1 — Health Care Naturally, The Future is Ours Confidential Application Application for Doctoral Review and Membership Passport sized photo General Information Please read before completing this application: 1. Complete the application in full. 2. Please print clearly or type all information. 3. Please do not staple application materials 4. Enclose a non-refundable application and membership fee of $325.00 5. Request official transcripts from each college, university, or professional program attended be sent directly to the AINM office. How did you hear about AINM? ______________________________________________________________