Instructions:
Please print and complete the following and send to:

The University of Natural Medicine
P.O. Box 3300
San Dimas, CA 91773

Submit Corresponding Academic Transcripts as Evidence

Name: Mr./Ms./Mrs./Dr./(Last)___________________(First)___________(MI)___
Maiden Name____________________________________________________
PresentAddress:__________________________________________________
(City)___________________(ST)_____(ZIP)_________(Country)____________
Student ID#:___________________________Telephone:__________________

1. Title of course for which credit is requested:
__________________________________________________Credits:_______
Title of course from academic transcript: ________________________________
School Name:_____________________________________________________

2. Title of course for which credit is requested:
__________________________________________________Credits:_______
Title of course from academic transcript: ________________________________
School Name:_____________________________________________________

3. Title of course for which credit is requested:
__________________________________________________Credits:_______
Title of course from academic transcript: ________________________________
School Name:_____________________________________________________

4. Title of course for which credit is requested:
__________________________________________________Credits:_______
Title of course from academic transcript: ________________________________
School Name:_____________________________________________________

5. Title of course for which credit is requested:
__________________________________________________Credits:_______
Title of course from academic transcript: ________________________________
School Name:_____________________________________________________


I acknowledge that the information I submit to the University is true and correct. I understand that failure to submit accurate information is considered adequate grounds for dismissal from the University and for revocation of credits granted.

Student Signature: __________________________________________________
Date: __________________