Instructions :
Please print and complete the following and send to:
The University of Natural Medicine
P.O. Box 4069
Santa Fe, NM 87502
Submit Corresponding Academic Transcripts as Evidence

Name: Mr./Ms./Mrs./Dr./(Last)_________________________(First)___________(MI)_____
Present Address: _________________________________________________________
(City)_________________________(ST)_____(ZIP)_________(Country)_______________
Student ID#:___________________________Telephone:__________________________

1. Title of course for which credit is requested:
   
   _____________________________________Credits:____________________
   
   Title of course from your academic transcript:
   
   _____________________________________School Name:_______________
   
   
   
2. Title of course for which credit is requested:
   
   _____________________________________Credits:____________________
   
   Title of course from your academic transcript:
   
   _____________________________________School Name:_______________
   
   
   
3. Title of course for which credit is requested:
   
   _____________________________________Credits:____________________
   
   Title of course from your academic transcript:
   
   _____________________________________School Name:_______________
   
   
   
4. Title of course for which credit is requested:
   
   _____________________________________Credits:____________________
   
   Title of course from your academic transcript:
   
   _____________________________________School Name:_______________
   
   
   
5. Title of course for which credit is requested:
   
   _____________________________________Credits:____________________
   
   Title of course from your 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________________