NEW JERSEY
INSTITUTE OF AYURVEDA
Distance Learning Practitioner
Training Program
Application for Admission
(__) Diploma in Ayurveda (Practitioner Program)
(__) Certificate in Ayurvedic Herbalism
(__)
Certificate in Ayurvedic Nutrition (__)
Certified Ayurvedic Esthetician
(__)
Foundation-Level Ayurveda
I. PERSONAL
INFORMATION:
Name (Last) _______________________________ (First) ___________________ (MI)
_______
Other name(s) by which the applicant is known ________________________________________
Mailing Address ________________________________________________________________
City _____________________________ State/Province ____________________ Zip
________
Telephone (Home) _______ - _______ - _________ (Work) _______ - _______ -
___________
S.S. No.:___________________ Email address _______________________________________
U.S. Citizen/Permanent Resident: ____Yes ____ No (if no, please complete the
next line)
Country of Citizenship __________________ Visa Type ____________ Issue Date
___________
Current Occupation: ___________________________ Employer _________________________
Emergency Contact : Name _______________________________________________________
Telephone (Home) _______ - _______ - ___________ (Work) _______ - _______
- ___________
Where did you hear about our program? _____________________________________________
_____________________________________________________________________________
If applying for the Diploma in Ayurveda (Practitioner) Program, please complete sections II, III, IV and V below.
II.
EDUCATIONAL INFORMATION:
Do you have a high school diploma or equivalency? ______ Yes ______ No
If yes, please indicate high school, location and date or, if equivalency, issuing
authority:
_____________________________________________________________________________
_____________________________________________________________________________
Whether or not you have earned a degree, please list all post-secondary schools
which you have attended
(including names, locations, dates of attendance, subject(s) studied and type
of degree or distinction awarded):.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Please list additional professional training you have received (including names
of training institutions,
locations, dates of attendance, and type of type of training):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
III. HOBBIES
/ AVOCATIONS / INTERESTS:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
IV.
ESSAY:
On a separate sheet of paper write a short (1,000 words or less) essay on: (1)
why you want to become an
Ayurvedic practitioner; (2) your future personal and professional goals; and
(3) how you might contribute to
the future development of the Ayurvedic profession. This may be sent separately
from your application.
V. REFERENCES:
Please attach to this application (or have sent to us under separate cover)
one or more letters of recommendation from
a personal references who know(s) you and can form a judgment as to your ability
to successfully complete
this program. This may be sent separately from your application.
VI. PAYMENT:
I enclose my
tuition payment in the amount of $_____________ (OR) I authorize you to charge
my credit card account
no. ________________________________ (expiration ___/20____) in the amount of
$___________
I affirm that the information I have provided is accurate to the best of my knowledge.
Signature ________________________________________ Date ______________
Print this application and mail it with the a[[ropriate tuition fee to:
The New
Jersey Institute of Ayurveda
Attn: Admissions
c/o Starseed Center for Yoga & Wellness
215 Glenridge Avenue
Montclair, New Jersey 07042.