UMBERS REFER TO CANDIDATE INSTRUCTIONS		Application for International Certification ICCAOM
1	PERSONAL INFORMATION
	NAME □ACUPUNCTURE □HERBOLOGY □OMP □OMD □QMRA □DNM
	last name (family name):						first								middle
	GENDER		□ male □ female	SOCIAL SECURITY NO./ ALIEN RECISTRATION NO.:								DATE OF BIRTH (MM/DD/YY):
	NAME AS YOU WISH IT TO APPEAR ON CERTIFICATE (MAXIMUM OF 30 CHARACTERS)
	HOME CONTACT INFORMATION: 中國語住所記錄/한국어주소기재:
	street address:										apt. no:
	city:					state:				country:						zip/postal code:
	home telephone:				home fax:									home E-mail:
	BUSINESS CONTACT INFORMATION								business name:
	street address:												suite no.:
	city:					state:				country:						zip/postal code:
	business telephone:							business fax:							business e-mail:

2	SPECIAL REQUESTS
	DIRECTORY	□ home	CANADA WITH DISABILITIES ACT	LANGUAGE
	PREFERENCE	□ business	REQUEST	in which language will you take the examination?
	(check one)	□ do not list	Do you have a documented disability	□ English □ Chinese □ Korean
			requiring special accommodation?
			□ yes □ no

Please review the

Candidate Information

before completing

this application

3	ELIGIBILITY CATEGORY	I am applying for certification based on the eligibility outlined in Section ll of the Candidate Information for (check only one):
	□ Formal Education Route -1CNT course certificate -Notarized copy of diploma -School transcript (sent directly from registrar`s office		□ Professional Practice Route -Notarized letters from 2 health care professionals -Notarized affidavits from 20 patients -Notarized affidavits from 2 professional members of the community	□ Apprecticeship -Notarized letter from preceptor or tutor -Repressentative sample of notes -Notarized copy of apprenticeship approval from state OR -Documentation of preceptor`s 5 years of practice prior to preceptorship		□ combination fo Training and Experience -A total of 40 points based on a review of criteria noted under other routes		State License Holder -Select eligibility route -Document: ∙Score report ∙Continuous or Professional practice ∙60 PDA points
	Please review documentation requirements as noted in Section ll of the Candidate Information
					Applicant Signature	:
							CONTINUED ON P.2

P.2 ICCA Application for International Certification in Acupuncture

4	EDUCATION AND TRAINING (CHOOSE ONLY ONE)
	▣FORMAL EDUCATION ROUTE:
	Be sure to include the requested documentation with your application
	School name:								Date of Graduation
	Type of training: (Optional)		□Traditional Chinese Medicine(TCM)	□Japanese Acupuncture			□Korean Acupuncture					□5 Element			□Other
	▣PROFESSIONAL PRACTICE or APPRENTICESHIP or COMBINATION ROUTE:
	Please complete all sections appropriate to your route of eligibility. See Section ll of the Candidate Handbook for more details
	Preceptor name:							No. of hours completed:
	School name:							No. of hours completed:
	Type of training: (Optional)		□Traditional Chinese Medicine(TCM)	□Japanese Acupuncture			□Korean Acupuncture					□5 Element			□Other
	Have you completed at least 4 years of practice within the last 8 years?												□YES	□NO
	How many years of training have you obtained in the field of Chines herbology?												□0-5 yrs	□6-10 yrs				□10+ yrs
	How many years have you practiced in the field of Chinese herbology?												□0-5 yrs	□6-10 yrs				□10+ yrs
	How many individual patients do you treat per year?												□0-100	□100-200				□200+
	What is your total number of patient visits per year?												□0-100	□100-200				□200+
5	PROFESSIONAL LICENSE(S):Please indicate any healthcare licenses currently held.
	□Acupuncture/Oriental Medicine				□Naturopathy						□Massage Therapy (LMT)						□Other
6	IDENTIFICATION
						PLEASE STAPLE ONE(1) PASSPORT- SIZE H\PHOTOS TO YOUR APPLICATION
		You will be required to show 1 forms of identification when you register at your test site. Both of these forms of identification must have a signature that matches your name as shown on the application. The required photo I.D. will be verified against the photo submitted on your application.

CONTINUED ON P.3

7	PROFESSIONAL ETHICS AND FITNESS TO PRACTICE LEGAL ACTIONS:
	If you answer "YES" to any of the questions below, you must, at the time of application, furnish information relating to the charges, accusations, or claims made against you. This documentation must include the claims or accusations, the evidence claimed by accusers to support their claims, your response, and the evidence to support your response. These documents will be forwarded to the ICCAOM Review and is Committee for confidential review. Further investigation may be necessary to determine your eligibility or certification status. you may not take the examination or be certified until this determination has been made and all requirements are met.
	Have you ever been a defendant in a litigation connected with a health care practice?		□ YES □ NO
	Have you ever been convicted of a felony or a practice-related misdemeanor?		□ YES □ NO
	Have you ever been dishonorably discharged from military services?		□ YES □ NO
	Have you ever been disciplined by a state board or health professional association?		□ YES □ NO
	Have you ever voluntarily surrendered a license to practice in any health care profession?		□ YES □ NO
	HEALTH STATUS:
	During the past two (2)years, has your physical health status interfered with your ability to practice health care for any significant time period (i.e., more than one (1)month)?		□ YES □ NO
	If you answer yes, please submit documentation from a health care professional familiar with your case attesting that you are no longer impaired and are currently physically capable of practicing.
	Have you ever been dependent upon any drug, including alcohol?		□ YES □ NO
	If you answer yes, please specify the nature of the dependency and what treatment you have undertaken. Attach an affidavit from your health care professional stating that the dependency is under treatment and does not interfere with your ability to practice.
	Have you ever had an emotional/mental illness that has impaired your ability to practice health care?		□ YES □ NO
	If you answer yes, please submit documentation from a health care professional familiar with your case attesting that you are no longer impaired and are currently capable of practicing.
8	STATEMENT OF UNDERSTANDING:
	The information i have provided is accurate, true, and correct to the best of my knowledge. I understand and agree to be bound by the policies, procedures, and Code of Ethics promugated by the International Certification Commission for Acupuncture and Oriental Medicine (ICCAOM). I agree to inform and release to ICCAOM and its agents all pertinent information related to situations that arie in connection information in this application or in connection with my certification. Therefore, i understand and agree that my failure to provide accurate, true, and correct information, respond to authorized ICCAOM requests for additional information, or abide by ICCAOM policies, procedures, or Code of Ethics shall be grounds for rejection of my application or denial or revocation of my certification. I hereby attest that i am taking this examination for purposes of certification and/or a licensing requirement in the state or municipality in which i have chosen to practice. I understand that International certification is NOT a substitute for my local and/or state lecensing requirements. I further understand that i am prohibited from transmitting information regarding examination questions or content in any form to any persom or entity, and understand that failure to comply with this prohibition may result in my certification being revoked and/or legal action being taken against me. I understand that my name will become part of the registry of the ICCAOM upon successful completion of the examination, unless i specifically request that my name not be released. Further, i attest that i have read the contents of the handbook and agree to abide by the policies and procedures outlined therein.
	THE QUALIFYING EXAMINATION 1.This is the oriental medicine skill qualification examination offered by ICCAOM-IPE, a non-governmental organization .2.The ICCAOM certificate might not be used as a licensed certificate for any kind of business in few countries that have regulations or a limitations for this concern such as Korea, Canada, U.S.A,and France, etc. 3.The examination fees and the application fees are not refundable. 4.Person who are believed to be cheating will receive a warning for minor acts of cheating. For more serious matters, a person's score will be canceled. 5.It is not strongly prohibited for you to disclose any questions appeared on the exam to others. If there is no signature of an applicant or an examinee on this form, even if he/she passed this exam, the result will be invalid, and any kind of claim will not be effective on this issue.6.This document is notarized. PRINT NAME:
	Applicant's Signature:
	Signature of Witness:	Date: