Samra University of Oriental Medicine :: Acupuncture and Oriental Medicine

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AFTER SENDING THIS APPLICATION ELECTRONICALLY, PLEASE PRINT OUT A COPY AND ATTACH THE APPLICATION FEE AND SEND IT BY REGULAR MAIL TO: SAMRA UNIVERSITY, ATT: BUSINESS OFFICE, 1730 W. OLYMPIC BLVD. 3RD FLOOR, LOS ANGELES, CA 90015. PLEASE NOTE ON THIS COPY THAT AN ORIGINAL WAS SENT ELECTRONICALLY AND WHEN. THANK YOU.

In accordance with Title IV of the Civil Rights Act of 1964, Title IX of Educational Amendments of 1972, Section 5 of the Rehabilitation Act of 1973 and Age Discrimination Act of 1975, Samra University of Oriental Medicine does not discriminate on the basis of race, color, religion, sexual preference, marital status, national origin, age, or mental limitation in any of its practices.

Please Note: Fields marked with * are required for proper submission.

GENERAL INFORMATION

*Applying for Entry in: Year:

*Applicant Name

Last (Family):
First:
Middle:
If known by any other Name Indicate:

*Email Address:

*Mailing Address

Street:
City:
State:	Zip:

Permanent Address (If other than current mailing address)

Street:
City:
State:	Zip:

*Telephone
Daytime: Evening:

In Case of Emergency Contact
Name: Phone:

Status Full-time Day Part-time Evening

*Prefer Instruction In English Chinese Korean

Have You Filed For Financial Aid? Yes No (If not, do you plan to? Yes No)

ACADEMIC HISTORY

*Name of High School Attended:

*Year of Graduation:

Colleges of Universities Attended (please list in chronological order)

School Major Degree From To

CITIZENSHIP STATUS

If you are a U.S. citizen or permanent resident, please indicate your ethnicity: (This information is used for reporting requirements for accreditation and financial aid only)

White/Caucasian Hispanic/Latino Black/African Oriental/Asian American Native American/Eskimo Filipino/Pacific Islander Other, please list

If you are NOT a U.S. citizen or permanent resident: Country of Citizenship:

Do you require and I-20 (for student visa processing)?
Yes (Include a $100 processing fee to your general application fee)
No Please indicate your immigration status:

Have you taken the Test of English as a Foreign Language (TOEFL)? Yes Test Score: No

*REFERENCES (preferably acupuncturists, college professors, and other professionals)

Name:
Phone:
Street:
City:
State:	Zip:
Name:
Phone:
Street:
City:
State:	Zip:

PERSONAL PROFILE

On a separate sheet of paper, please submit a one-paged, typed essay describing your capabilities and reasons for pursuing a career in Oriental Medicine.
*How did you first learn about Samra?
(Please be specific)
The following information has no bearing on the admission decision. It is collected for statistical purposes only.
SEX: Male Female
DATE OF BIRTH:
BIRTHPLACE:
MARITAL STATUS: Married Single Other

APPLICATION CERTIFICATION Enclosed is my non-refundable Application Fee of $100.00. I certify that the information provided on this application is accurate and complete. If I am accepted as a student, I agree to abide by all rules of the University. ________________________________________________ Signature of Applicant Date

AFTER SENDING THIS APPLICATION ELECTRONICALLY, PLEASE PRINT OUT A COPY AND ATTACH THE APPLICATION FEE AND SEND IT BY REGULAR MAIL TO: SAMRA UNIVERSITY, ATT: BUSINESS OFFICE, 1730 W. OLYMPIC BLVD. 3RD FLOOR, LOS ANGELES, CA 90015. PLEASE NOTE ON THIS COPY THAT AN ORIGINAL WAS SENT ELECTRONICALLY AND WHEN. THANK YOU.