Pacific College of Oriental Medicine Pacific Symposium

As long as you cannot forgive the next man for being different, you are still far from the path to wisdom. - Chinese wisdom

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Pacific Symposium Speakers - Personal Information

This information is REQUIRED and will be submitted for Continuing Education approval. Complete Section 'A' if you are an acupuncturist; otherwise, go to SECTION 'B' . Due Friday, March 30, 2007.

*=Required Fields

	Personal Information

*First Name:
*Last Name:
Title(s):
Address:
City:
State:
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*Telephone:
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Other:
Best way to contact you:	Phone Email Mail Fax

	SECTION A:

	Are you free of any disciplinary or probation imposed by the board?
	yes No

	License Number	State



	Education
	School Name and Location	Degrees Earned	Year



	SECTION B

	Title of License or Certificate	License Number and Name of State