Universal Residency Application
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1
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3Universal Residency Application
Personal Data Form
My degree is from:
Bastyr University
Boucher Institute of Naturopathic Medicine
RECENT PHOTO
Canadian College of Naturopathic Medicine
National University of Health Sciences
(OPTIONAL)
National College of Natural Medicine
Southwest College of Naturopathic Medicine
To upload Photo, it must be in PDF
University of Bridgeport College of Naturopathic Medicine
format.
If not in PDF, a JPEG file may be
I am applying for a:
First Year Residency Position
sent as an attachment during
Second Year Residency Posit
submission.
Third Year Residency Position (if any are available)
I will complete (or have completed) my Naturopathic Doctor degree on :
December
2020
Legal Name
,
Sex
F
M
Last Name
First Name
MI
Preferred Name
Former Last Name (S)
Home Phone
E-mail 1
Cell Phone
E-mail 2
Best way to contact
Home Phone
Cell Phone
Email 1
Email 2
Mail Current Address
Mail Permanent Address
Current Address
Street Address
City/Town
State/Province
Zip Code
Country
Other instructions
Use Address Until
December
2020
Permanent Address
Street Address
City/Town
State/Province
Zip Code
Country
Citizenship:
U.S.
U.S. Permanent Resident
Other
Country
Visa Type/Number
If citizenship is "Other", will your current visa status allow you to complete the entire term of training program?
Disclosure Statements
Please answer the following questions. The fact that a conviction and/or criminal offense has been pardoned, expunged or dismissed, or that your
civil rights have been restored does not mean that you can answer “No” to questions 1 through 8.
1.
Have you ever been arrested, charged with, convicted of, or entered into a plea of no contest to a felony or a misdemeanor?
Yes
No
2.
Have you ever had a license/certificate, including a driver’s license, suspended or revoked by any agency?
Yes
No
3.
Have you ever been disciplined by any agency for an act of unprofessional conduct as defined in Arizona Revised Statues, Section 32-1501?
Yes
No
This is for Arizona only.
4.
In lieu of disciplinary action by an agency, have you ever entered a consent agreement or stipulation with a licensing agency?
Yes
No
5.
Do you have a complaint pending before any agency?
Yes
No
6.
Have you ever been found guilty of being medically incompetent?
Yes
No
7.
Have you ever been a defendant in any malpractice matter that resulted in a settlement or judgment?
Yes
No
8.
Do you have any medical condition that in any way impairs or limits your ability to practice medicine?
Yes
No
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