Online Application for Admission

1. Last Name First Name Middle Name
2. Prior Name(s) Preferred Name
3. Address
4. City State Zip Code
5. Billing Address (if Different)
6. City State Zip Code
7. Home Phone Work Phone Mobile/Pager Email Address
8. Gender Select One... Male Female Do you plan to apply for financial aid? Select One... Yes No

1. 1st Contact Relationship to Applicant
2. Address
3. City State Zip Code
4. Phone
5. 2nd Contact Relationship to Applicant
6. Address
7. City State Zip Code
8. Phone

1. US/Dual US Citizen Other Citizenship US Permanent Resident
2. If dual, specify other citizenship
3. Country Visa Type
4. Visa, Green Card Number Citizen of

1. Institution/Location Major/Degree Dates Attended Units Completed
2. Institution/Location Major/Degree Dates Attended Units Completed
3. Institution/Location Major/Degree Dates Attended Units Completed

1. Employer Location Position Phone Dates of Employment
2. Employer Location Position Phone Dates of Employment
3. Employer Location Position Phone Dates of Employment

1. Select One... AOMA Web Site Current Student/Alum Natural Healers Professional Clinic/Student Clinic Patient Staff/Faculty Open House Austin Woman Magazine Acupuncture Today Other
2. If other:

1. Yes No
2. If yes, give details below:

1. Yes No
2. If yes, give details below:

(Information in this section will be used for statistical purposes only and is strictly voluntary.)

1. Select One... African American/Black American Indian/Alaskan Native Asian/Pacific Islander Caucasian/White Hispanic/Latino Non-Resident Alien Other

I certify that the information supplied by me on the form is true and correct to the best of my knowledge. If any of the information on this form changes between now and my matriculation at AOMA, I will notify the admissions office as soon as possible. I understand that failure to do so may result in withdrawal of my application and/or the offer of admission.