Application for Admission: Diploma of AcupunctureComplete this form to apply to Autumn Institute of Health's Diploma of Acupuncture Program.If you have any questions, please email us at info@autumnhealth.org.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Enrolment Stream *Standard EntryDistance Entry (first term online)Health Care Provider EntryStatus *Full-timePart-timeFull-time or part-time status can be changed during the program. Please select your intention for your first term.Name *FirstLastPreferred Name (if different)Preferred PronounEmail *Phone *Address *Address Line 1Address Line 2CityState / Province / RegionPostal Code--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Citizenship *Canadian CitizenCanadian Permanent ResidentOther (please select)CitizenshipPlease write the country of your citizenship.Emergency Contact *FirstLastEmergency Contact: Phone Number *QualificationsAcademic Information and Credentials *Please provide the following information for all high schools, colleges and universities that you have attended in the order of attendance from most to least recent: Institution Names, Dates of Attendance, Major, Degree/Qualifications Earned*English Language Skill *English is my first language.English is not my first language but I have done academic work in English.English is not my first language but I am fluent.Other (describe below)Please select the one that best describes you.If English is not your first language, please describe your English language skill level.Two Letters of ReferencePlease upload letters of reference from two people who know you in a professional or academic context and are able to speak to your character and ability to complete a diploma program.Letters of Reference File Upload * Click or drag files to this area to upload.You can upload up to 2 files. Upload both letters here.Supporting DocumentsTranscripts * Click or drag files to this area to upload.You can upload up to 10 files. Please include all transcripts for any post-secondary education you have completed. If you are a transfer student, please include transcripts or grade reports of the courses you have completed so far.Current Resume/CV * Click or drag a file to this area to upload. Passport-style Photo * Click or drag a file to this area to upload. Current government-issued photo ID (such as a driver’s license or passport)* * Click or drag a file to this area to upload. Attestations I attest that all information provided on this application is accurate. *YesNo I am aware that deliberate falsification of any admissions information may be grounds for rejection or dismissal from Autumn Institute of Health. *YesNoApplication FeePlease send the $75 application fee by e-transfer to info@autumnhealth.org. Alternatively, you may contact us to arrange for cash or cheque payment.Submit