Application Form



The International Institute of Original Medicine (IIOM) Application Form

Personal Infomation


Your Name (required):

Your Email (required):


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:


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:

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.