Consumer Reports Homeopathy by gbp12616


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									        American Medical College of Homeopathy
                 Application for Admission
       Doctor of Hahnemannian Principles Program
Instructions: Please read the application in entirety before completing. Please do not
staple application materials.
       1. Complete the application in full.
       2. Enclose a non-refundable application fee of $75.
       3. Request official transcripts from each college or university attended
              sent directly to the AMCH Office of Admissions (must be received
              prior to your scheduled interview).
       4. Request three Letter of Recommendation Forms. One of these should be
              from an academic teacher, one occupational and one personal.

Part 1. Vital Information

            Last                        First                        Middle
Social Security Number:                             Date of Birth:

Place of Birth:                                  Gender:    Male              Female

Mailing Address:

City                      State         Zip           Telephone (Day)

Country                                 Email Address

Permanent Mailing Address:

City                      State         Zip           Telephone (Day)
Telephone (Evening)                              Cell Phone

Citizenship:     U.S.      Other (specify country)
Type of Visa (if not US Citizen):

Emergency Contact Name and Address:

Program:             Online Option               Campus Option

Are You Applying for Advanced Standing?            No                Medical Only
      Homeopathic Only            Medical and Homeopathic

Are You Applying for Online or Campus based option?
           Campus             Online

Are You Applying for a Combined Degree Program?            No
      ASU Research Program        PIHMA Asian Medicine Program

                               How did you hear about this school?


                                Have you ever applied to AMCH before?

Describe any previous homeopathic training?

Are You Nationally Certified in Homeopathy?                   Yes           No
      (If yes, please attach a copy of your certificate)

Describe any previous medical training?

Do you hold any medical degrees (if yes please attach a copy):
     MD               RN                 OT
     DO               NP                 DDS
       ND                   PA                   Other
       LAc                  LMt

Are You Nationally Certified Medically?                  Yes   No
      (If yes, please attach a copy of your certificate)

Highest Level of Education Received

Part Two: Personal Information

Have you ever been convicted of, pled guilty or no contest to, or forfeited bail
for any criminal conduct under law or ordinance, excluding only minor traffic
violations (if yes, please attach a full explanation).

What experience if any have you had with alternative medicine or

What health issues have arisen in your life and how did you deal with them?

Part Three: Essays
All essays combined should be no more than four pages double spaced.

1. Write an essay about why you wish to study homeopathic medicine. Describe the
events that led you to this decision. Why would you be an asset to the homeopathic
2. Describe one of the most difficult moments in your life and how you were able to
cope through that experience. How did this experience change you?
3. Who has been one of your greatest role models in your life. What traits or
attributes do they possess that you particularly admire and aspire to?
4. If you were previously denied admission to AMCH or offered admission to AMCH but
did not enroll, describe why you feel that now is the right time to apply and how your
application has been strengthened.
5. If you are transferring to AMCH, explain your reasons for transferring.
Part Four: Education
List all accredited or candidate post-secondary institutions in order of
attendance beginning with the most recent. If you are still enrolled, indicate
the expected date of completion.

     Institution         City, State     Dates Attended          Degree, Year

Have you completed all prerequisites for admission (if not you may still apply
as long as you complete all prerequisites prior to entering the program)?
                    Yes          No

List all courses required for admission and any courses that are upcoming or
in progress. Note that 1 semester credit=1.5 quarter credits. Grades below
“C” will not be accepted and science classes must be completed in the last 10

Prerequisite   College   Course Title    Lab       Credits      Grade     Completion

Biology (12

(12 semester

Physics (6

(6 credits)
Part Five: Employment History
Attach a professional resume listing employment beginning with your most
recent employer. Include any health care experience.

Have you ever been licensed as a health care provider (if so, attach a copy of
your license?   Yes      No

If you are a health care provider, has your health care license ever been
suspended or revoked (if so, please attach an explanation)?

   Yes        No

What has been your most challenging work experience and how did you
overcome it?

Do you have any physical or educational challenges (for example dyslexia)?

In connection with my application with the American Medical College of Homeopathy, I
understand that a consumer report, which may contain public records information, is
being requested.

I affirm that the foregoing information is true and accurate to the best of my
knowledge. I understand that any misrepresentation or falsification, including failure to
report any college or university attendance, is sufficient cause for denial of admission
and cancellation of enrollment and/or any credits earned. I further understand that all
application materials are the property of the American Medical College of Homeopathy
and cannot be returned. This information may be reproduced for use during my

Signature                                              Date
Please mail the application materials to:
      Admissions Office
      American Medical College of Homeopathy
      1951 W. Camelback, Suite 300
      Phoenix, AZ 85015

Before mailing out your application be sure to include:
     1. Completed Signed Application
     2. Check for application fee
     3. Resume
     4. Essays
     5. Arranged for transcripts to be sent to AMCH?
     6. Arranged for three letters or recommendation to be sent to AMCH?

AMCH, in compliance with state and federal laws and regulations, does not discriminate on the basis of race, color,
national origin, religion, sex, sexual orientation, marital status, age, disability, or veteran’s status in any of its
policies, procedures, or practices. This nondiscrimination policy covers admission and access to, and treatment and
employment in, College programs and activities, including but not limited to academic admissions, financial aid,
educational services, and employment.
                    American Medical College of Homeopathy
                       Letter of Recommendation Form

Part One: This part to be completed by the applicant.

Applicant’s Name:
                             Last                First                    Middle
Applicants Address:
                         Street                  City             State            Zip
Applicants Phone:

Part Two: this part to be completed by the recommender.

 1. The above named individual is applying for admission to the American Medical
College of Homeopathy. Please send a letter of reference indicating the applicant’s
character, quality of work and personal characteristics. Please be as candid as possible
in the attached letter.
2. Mail this completed form and your letter of reference to: AMCH Admissions Office,
1951 W. Camelback, Suite 300, Phoenix, AZ 85015.

Recommender’s Name


Position                     Telephone                   E-mail

Signature                                                Date

    Characteristic       Excellent   Very Good   Good           Fair       Poor          Not Observed

Problem Solving Skills
Organizational Skills
Self Discipline
Study Habits
Interpersonal Skills
Written Skills
Oral Skills
Bus Management Skills
                          American Medical College of Homeopathy
                     1951 W Camelback Rd, Suite 300, Phoenix, AZ 85015
                             602-347-7950; Fax 602-864-2949


Applicant’s Name:

Applicant’s Date of Birth:                          Applicant’s SS#:

Drivers License #:                                        State Issued:

Address #1

City:                    State:       County:                          Zip:

Address #2

City:                    State:       County:                          Zip:

One or all of the following:
Criminal Records □ Credit History National Wants & Warrants □ Professional License □

Company requesting the background inquiry: American Medical College of Homeopathy

For residents of California, Minnesota and Oklahoma only: You will be provided with a free copy
of any consumer reports or investigative consumer reports on you if you check the box below.
Applicant requests a copy of the report: □ Yes □ No This form constitutes a request for services.
The services will be provided by, hereafter “ICU”. The Client agrees that it shall be
responsible for any and all actions that it takes based on any reports ICU provides.        The Client shall
defend, indemnify, and hold ICU and/or its subcontractors harmless from any and all losses, claims,
demands, liability, causes of action, judgments, costs, and attorney fees arriving out of this
Agreement, except to the extent that ICU is negligent. The Client hereby agrees to hold ICU and its
officers, agents, employees, subcontractors, and independent subcontractors harmless on account of
any expense, cost, or damage resulting from the publishing by the Client, or the employees, agents,
or independent subcontractors of the Client, of any report information provided by ICU contrary to the
terms of this Agreement or applicable laws, rules, or regulations. The Client certifies that the
information in the reports from ICU will not be given to or resold to any other person or user and that
the requests for information will not be made except within compliance with U.S.C. 1681, et seq.,
titled the Fair Credit Reporting Act. The Client agrees not to disclose the contents of the reports
provided to the applicant hereafter “Subject”. The Client understands that they are obligated to inform
the Subject of any report provided hereunder if adverse action was taken in whole or in part based on
that report. If the Subject would like to review his/her report, the Client shall refer the subject to ICU
for disclosure. It is agreed and understood that ICU does not warrant, vouch for, or authenticate the
reliability of the information provided hereunder, except that the information has been accurately
reported from the source. The client gives signed permission to ICU to investigate, Criminal, Credit
and Driving histories, as well as any other information listed on the application. The subject has
been informed all information will be held in confidence. Client also agrees that all reports can take 24
to 72 courthouse hours to retrieve.
Notice to New York Applicants: Under Article 25 Section 380-g of the New York General Business Law,
should a consumer report received by an employer contain criminal conviction information, the
employer must provide to the applicant or employee who is the subject of the report, a printed or
electronic copy of Article 23-A of the New York Correction Law, which governs the employment of
persons previously convicted of one or more criminal offenses.

Applicant:                                                                Date:

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