Center for Traditional Medicine
Registration

PMB 214, 1001 Cooper Point RD SW 140
Olympia, Washington 98502 USA
Phone: (360) 262-6175
Fax (253) 276-0084

You may mail in your application or you may fill out our web form.

To mail in application:

Download and fill out the application form and to send to us:
(Please send your printed application and payment to Center for Traditional Medicine. If you have questions do not hesitate to contact Dr. Leslie Korn, Director via email:

To use Online application:

(Please fill out this form and press the submit button, at bottom of page, if you are paying with a credit card only.

Directions:

Enter information in to each field and press Tab or click in next box to move on.
Pressing RETURN will submit the form.

Section 1: Personal Information

Certificate Title
Enrollment Year
Name
Address
City/Town
State/Province
Postcode
Country
Phone Work
Phone Home
Fax
Email
Age
Sex: Female Male
Institution Affiliation

Section 2: Questions

Current Degrees, School, and date of receipt: ( e.g. BA University of Washington, 2000., etc
Current Licenses or Certificates (e.g. CNT, Nutritional Therapy Association, Olympia, 2005)
What is your academic, professional, or other background?
(Please use 1 - 2 pages.)
What are your goals for internship, certificate or MA degree?
(Please use 1 - 2 pages.)
Are you applying for the Masters Degree option? Yes No
Proposed Entrance Date?

Section 3: Financial

Note: There is a $50 application fee (Non-refundable) to process your application.

Payment Method Visa MasterCard American Express
Card Holders Name
Card Number:
Expiration Date: Month Year

Registered APTA Educator and Practitioner

Center for Traditional Medicine Registration

To mail in application:

To use Online application:

Directions:

Center for Traditional Medicine
Registration