First Name:


Last Name:


Age:


Sex:
Male
Female

Address 1:


Address 2:


City:


State/Province:


Country:


Postal/Zip Code:


Phone - Home:


Phone - Mobile:


Email:


Fax:


I plan to enroll in the new accredited 4-Year Traditional Tibetan Medicine Certification Program. ($2,500 per semester)

Education: (Please include school, degree and dates attended.)


Training: (Please included program/workshop, classes, instructor and dates attended.)


References: (Please include at least one professional, one personal and one academic reference.)


Do you have any of the following special skills?
Fundraising/development
Organization/secretarial/typing/transcribing
Farm management or agricultural experience

Do you plan to enroll in some classes for CEU (Continuing Education Unit) credits?
Choose... Yes No

Please write a brief essay on why you wish to attend the Shang Shung Institute Tibetan Medicine Program [Please include background or personal capacity you have which has prepared you for a rigorous program in Tibetan Medicine, your goals for the future and other relevant information]:


Request dorm accommodation on-site: (On-site accommodations available for up to a potential of two semesters only.)
Choose... Yes No

Do you have previous experience with cooperative living?
Choose... Yes No