Training Program for Japanese Acupuncture and Moxibustion,

Meiji University of Integrative Medicine

Application Form

1) Name of Applicant (as in the passport)

Family NameFirst Name Middle Name (if applicable)

, ,

2) Nationality (as shown in the passport)3)Sex

□Male □Female

1 / 3

4) Date of Birth (please write out the month as in “April”)5) Age (as of the date of completion)

Date Month Year

6) Language

native languagepreferred language of communication □English □Japanese

7) Present Position and Current Duties

□student:

name of the school enrolled

□employee:

type of organization: □University□Hospital (public)□Hospital (private)

□Other(please describe)

name of the organization

department/division

□independent practitioner

8)Qualification(s)

□Acupuncturist (incl.Oriental Medical Doctor)□Physician□Nurse□Chiropractor□Physiotherapist

□Others (please describe)

9)Contact Information

Office / Address:
Phone: / E-mail:
Home / Address:
Phone: / E-mail:
Contact person in emergency / Name: Relationship to you:
Address:
Phone: / E-mail:

10)Desired Period of Training (dd/mm/yyyy)

from to

request on the period/days/hours (if any)

11) Educational Record (Higher Education)

Institution / City/Country / Period (month / Year) / Degree obtained / Major
From / To

12) Job Record (After graduation)

Organization / City/Country / Period / Position or Title
From / To

print name

signaturedate (dd/mm/yyyy)///

Checking List of the Field of Interest

The following is the optional list for the applicant(s) who have specific interests/requests on the program.

The contents of the training program may be modified according to the request by the applicant(s).

Note that the provider(s) will not always comply with the request.

Check List of the Individual Program

1. Clinical Observation

□Acupuncture and Moxibustion Center

field of interest

□Musculoskeletal□Internal Organs□Sports Injury□Psychological □Paliative Care □Pain Management

□Traditional Japanese Style Acupuncture and Moxibustion Technique

□Western Medical Style Acupuncture and Moxibustion Technique

□Electroacupuncture

□Integrative Medicine Center

field of interest

□Overview of Integrative Medicine

□Kampo (Japanese Herbal Medicine)

□Aroma Therapy

□Massage□Judo-Seifuku Therapy

2. Lecture / Practical Training

□Education at Meiji University of Integrative Medicine□History of Japanese Acupuncture and Moxibustion

□Diagnostic Method of Japanese Acupuncture and Moxibustion □Japanese Acupuncture Technique

□Japanese Moxibustion Technique□Trigger Point Acupuncture Technique □Low back pain and sciatic disorders

□Acupuncture and Moxibustion for Parkinsonism □Acupuncture and Moxibustion for Gastrointestinal Functions

3. specification of the interest / request (if any)

name of applicant date

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