Application Form

This application is for Initial Exam takers only. If you need to retake a section or sections of the exam, please download the Retake Exam form and send it in with a signed Proctor Agreement.

Clicking the blue tabs will open the separate sections to fill out. Please enter as much information as you have in all these sections.

Which Exams Are You Applying For (check any that apply):
Homeopathy (all) Human Health Services Case Analysis Exam

I am requesting exemption for the Human Health Sciences exam, as I am a licensed primary health care provider (MD, DO, ND, DC, Lac, OMD, RN, etc), and I have attached a copy of my state issued license.

Personal Information

First Name: Last Name:

Licenses/Certifications: Other Credentials:

License Information:

Clinic Name:

Street Address:

City: State/Province: ZIP or Post Code:

Country: (complete ONLY if not USA)

Work Phone: Home Phone:

FAX:

Phone Information:
i.e. call before sending FAX

Email Address: Web Site:

Summary of Homeopathic Training:

#1 Program Name: Hours:

#2 Program Name: Hours:

#3 Program Name: Hours:

Other Programs - (Total for all others) Hours:

Seminars & Conferences - (Total for all of them) Hours:

TOTAL HOURS:

Supervised Clinical Experience (Apprenticeship):

(use mm/dd/yyyy format for dates)

From: To: Contact Hours: Avg. Pts/week-New: Follow-up:

Supervisor(s):

From: To: Contact Hours: Avg. Pts/week-New: Follow-up:

Supervisor(s):

Practice Experience:

Beginning Date: Approx.Tot # of new patients seen:

Current: Average # of New Patients/Week: Percent of practice that is homeopathic %

Average length of initial visit for a patient with a chronic complaint (NUMBER of hours):

Types of cases commonly seen: (240 Characters - MAX) (use tenths for partial hours, e.g.1.5) Other Qualifying Training or Experience:(240 Characters - MAX)

Health Sciences Training or degrees (240 Characters - MAX) : Includes: anatomy, physiology, pathology
CPR Training (Organization and Date) (240 Characters - MAX) :

NOTE:If this form is submitted by mail, FAX, etc., instead of electronically,an additional fee
must be included with the application.

Please enter the code to the right of the text box.

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