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TEXAS COLLEGE OF TRADITIONAL CHINESE MEDICINE

By Eva Hudson,2014-09-25 12:56
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TEXAS COLLEGE OF TRADITIONAL CHINESE MEDICINETEXA

TEXAS COLLEGE OF TRADITIONAL CHINESE MEDICINE

     4005 Manchaca Road Telephone: (512) 444-8082

    Austin, Texas 78704 Office Fax: (512) 444-6345

    www.texastcm.edu info@texastcm.edu Place your

    photo here

     Application Form for 2012 Summer Camp Program

Please note: Applications are reviewed on the first-come, first-serve basis to determine the applicant’s

    eligibility. A notification of acceptance will be sent to the applicant upon completion of the review.

A. APPLICANT DATA (Please print or type all information; sign and date)

    Name:____________________________________________ SSN (if any):____________________

     Last First Middle

    Mailing Address:___________________________________________________________________

     Street/P.O. Box City State or Country Zip or Postal Code

    Home phone:________________ Work Phone:________________ Date of Birth:________________

    Email: _____________________ Passport No. ___________________________

    Sex (circle one): M F Marital Status: Single, Married, Divorced, Widowed

    Are you a U.S. Citizen?_______ If "NO", list VISA type or residency status:_____________________

    Country of Birth: ___________ Are you an international student in the USA? ___________________

    Driver's License Number (if any):___________________ State:_______ Expires:________________

Emergency contact information:

    First person’s name:_____________ __________Relationship to the applicant: _________________

    Address____________________________ City:_______________ State:________ Zip:_________

    Home Tel #:____________ _____________ Work Tel #:__________________________

    Second person’s name:_____________ _______Relationship to the applicant: __________________

    Address____________________________ City:_______________ State:________ Zip:_________

    Home Tel #:____________ _____________ Work Tel #:__________________________

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    B. EDUCATION (List all colleges & post-secondary schools attended, without exception):

School or College City and State Dates Attended Degree(s) & Major

    ____________________________________________________________

    ____________________________________________________________

    ____________________________________________________________

    ____________________________________________________________

    ____________________________________________________________

    List any special honors/recognition received: ________________________________

    ____________________________________________________________

C. WORK & PROFESSIONAL EXPERIENCE (beginning with the most recent)

Dates Job Title Name of Organization & Location Nature of Work

    ____________________________________________________________

    ____________________________________________________________

    ____________________________________________________________

    ____________________________________________________________

    ____________________________________________________________

    D. Summer camp program fee includes: Two weeks of lodging (2 people per room), three

    meals daily, classes, trips and tours, as well as travel insurance.

    E. Non-covered fees: non-refundable application fee of US$75; round-trip air ticket; and

    personal spending money.

F. Payment schedule:

    1. Application fee: US$ 75;

    2. Total costs: US$ 4,500;

    3. If the application and full payment are received by March 15, 2012, there will be

    US$ 400 discount (so total costs will be US$ 4,100).

G. Refund policy:

    1. Before May 15, 2012, there will be a refund of 90% of the total full payment;

    2. After May 15, 2012, there will be no payment refunds made to the applicant.

    H. I certify that, to the best of my knowledge, all statements made in this application are

    complete and true. I understand that any falsification as well as failure to submit all

    required documents may result in denial of this application.

Signature: ______________________________________ Date: ___________________

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