Osteopathic Practice And Science Diploma Program Application Form

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Osteopathic Practice and Science Diploma Program Application Form
P
I
Please fill in all of the spaces. If not applicable to you, indicate “N/A”
ERSONAL
NFORMATION -
Family (Last) Name:
Given/First Name (legal):
Middle Name:
Previous /Maiden Name (if applicable):
Email Address:
Apt/Suite Permanent Street Address
City
State/Province
Postal Code/Zip
Country
Telephone – Mobile:
Telephone – Home:
Telephone – Business:
Birth Date: (year, month, day)
Gender:
First Language (must complete):
(y)____/(m)____/(d)____
Male
Female
English
French
Other
Residency Status:
Date of Entry into Canada (if applicable):
Canadian Citizen
Landed Immigrant
Study Permit
Other Visa
(year) _______ (month) _______
Please complete all of the spaces below. If not applicable to you, indicate “N/A”.
I
E
DUCATIONAL
NFORMATION
Secondary school transcripts and transcripts for the most applicable* education in post secondary (or most current) must
be mailed directly from the institution to AOS head office as part of your application package. Please use a separate paper to record additional
Institutions if necessary.
i) Post Secondary Institution #1 (most recent)
City
# of semesters in program
# of semesters completed
Province/State/Country
Degree, Diploma or Certif i cate Received
No
Yes
i) Post Secondary Institution #2
City
# of semesters in program
# of semesters completed
Province/State/Country
Degree, Diploma or Certif i cate Received
No
Yes
ii) Secondary Institution Name (most recent)
City
Last Grade Completed
Year of Completion
Province/State/Country
Secondary School Diploma Received
No
Yes
Related Education History
Have you received a post-secondary credit in Health Sciences ?
No
Yes
Do you have post secondary education that is similar to education taught at AOS such as health sciences or research?
No
Yes: Please describe__________________________________________________________________________________________
* most applicable refers to education that is comparable to that taught at AOS such as health sciences and research

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