Application Form The International Institute of Original Medicine (IIOM) Application Form Personal Infomation Title: ---Mr.Miss.Mrs.Ms. Your Name (required): Your Email (required): Phone: Home Address: Educational History High School (or equivalent) Name: School Address: Date of Completion: College (last attended) Name: College Address: Date of Completion: Highest Degree and Major: Graduate YesNo Other Education: (Please list all other educational achievements including correspondence courses, vocational training, seminars, workshops, etc. Please Note: All types of formal education must be verified in writing, i.e., Transcripts or Diploma. Attach an additional sheet, if necessary: Referred By: IIOM Study Intent IIOM Study Intent: ---Doctor of Naturopathy in Original Medicine (DNOM)Master of Science in Original Medicine (MSOM)Bachelor of Science in Original Medicine (BSOM)Certified Nutritional CounselorCertified Herbalist in Original MedicineCertified Medical MissionaryIndividual Course If Individual IIOM course was selected: Submit and Payment The IIOM one-time registration fee of $40.00 must be paid in full at the time of submission of the IIOM Application Form. Students may elect to pay for individual courses, one at a time, when working towards completion of a certificate program or degree program. Tuition must be paid in full before receiving coursework. IIOM also offers tuition installment payment plans. a.TUITION REFUND POLICY: No refunds are given subsequent to 10 days after enrollment. IIOM mailing address is: IIOM P.O.Box 506 Smithfield, VA 23431 Please call our Enrollment Department if you have any questions - (410) 884-9319 After you click the Send button you will be taken to the Paypal Payment page.