Last Name:__________________________ First Name:______________________ Degree:_______ Address:___________________________________ Apt.______ City:________________________ State:______Zip:_______________Country:____________Telephone:________________________ Fax:_______________________________ E-Mail:________________________________________ Specialty:______________________________License Number: _____________________________ PRIOR ACUPUNCTURE TRAINING: I have taken courses in acupuncture:____Yes. ____No. I am certified in acupuncture:____Yes. ____No. State and Certification Number:________________________________________________________ Sponsor(s):________________________________________________ Date:___________________ Sponsor(s):________________________________________________ Date:___________________ I AM ENROLLING IN THE FOLLOWING: ____Complete comprehensive program (300 credit hours)............$5200.00 (Includes tuition for China Internship but does not include air fare, room and board) (First course in this program is February 20, 21, 22, 2009 Individual components as indicated (25 credit hours per component): 2009 Schedule: ____February 20, 21, 22, 2009 ____March 20, 21, 22, 2009 ____April 17, 18, 19, 2009 ____May 15, 16, 17, 2009 ____June 19, 20, 21, 2009 ____July 17, 18, 19, 2009 ____September 25, 26, 27, 2009 ____October 23, 24, 25, 2009 Registration (Per component fee): ____Member of the New York Society of Acupuncture..................$350.00 ____Non-Member of the New York Society of Acupuncture.........$600.00 Late Registration (3 weeks prior to start of each component): ____Member of the New York Society of Acupuncture..................$400.00 ____Non-Member of the New York Society of Acupuncture.........$650.00 China Internship: August 24-September 6, 2009 (100 Clinical Training Credit Hours): (Includes tuition but does not include air fare, room and board) Registration includes a certificate, a group photo and a banquet ____Member of the New York Society of Acupuncture.................$2000.00 ____Non-Member of the New York Society of Acupuncture........$3000.00 Late Registration: Post marked after June 30, 2009 ____Member of the New York Society of Acupuncture.................$2200.00 ____Non-Member of the New York Society of Acupuncture........$3200.00 Please print and fill out application. Call (212) 876-9781 for questions. Mail application and check in the full amount, payable to the American College of Acupuncture, to: American College of Acupuncture c/o Dr. Peter Teng, Secretary/Treasurer 1021 Park Avenue New York, NY 10028