APPLICATION FORM [UK]APPLICATION FORM [UK] Name(Required) Title MissMr.Mrs.Ms.Dr.Other Forenames Surname Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Telephone 1(Required)Telephone 2Email(Required) Enter Email Confirm Email Profession(Required)Date of Birth(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Nationality(Required)AfghanÅland IslandAlbanianAlgerianAmerican SamoanAndorranAngolanAnguillanAntarcticAntiguan or BarbudanArgentineArmenianArubanAustralianAustrianAzerbaijani, AzeriBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBeninese, BeninoisBermudian, BermudanBhutaneseBolivianBonaireBosnian or HerzegovinianMotswana, BotswananBouvet IslandBrazilianBIOTBruneianBulgarianBurkinabéBurundianCabo VerdeanCambodianCameroonianCanadianCaymanianCentral AfricanChadianChileanChineseChristmas IslandCocos IslandColombianComoran, ComorianCongoleseCook IslandCosta RicanIvorianCroatianCubanCuraçaoanCypriotCzechDanishDjiboutianDominicanEcuadorianEgyptianSalvadoranEquatorial Guinean, EquatoguineanEritreanEstonianEthiopianFalkland IslandFaroeseFijianFinnishFrenchFrench GuianeseFrench PolynesianFrench Southern TerritoriesGaboneseGambianGeorgianGermanGhanaianGibraltarGreek, HellenicGreenlandicGrenadianGuadeloupeGuamanian, GuambatGuatemalanChannel IslandGuineanBissau-GuineanGuyaneseHaitianHeard Island or McDonald IslandsVaticanHonduranHong Kong, Hong KongeseHungarian, MagyarIcelandicIndianIndonesianIranian, PersianIraqiIrishManxIsraeliItalianJamaicanJapaneseJordanianKazakhstani, KazakhKenyanI-KiribatiNorth KoreanSouth KoreanKuwaitiKyrgyzstani, Kyrgyz, Kirgiz, KirghizLao, LaotianLatvianLebaneseBasothoLiberianLibyanLiechtensteinLithuanianLuxembourg, LuxembourgishMacanese, ChineseMacedonianMalagasyMalawianMalaysianMaldivianMalian, MalineseMalteseMarshalleseMartiniquais, MartinicanMauritanianMauritianMahoranMexicanMicronesianMoldovanMonégasque, MonacanMongolianMontenegrinMontserratianMoroccanMozambicanBurmeseNamibianNauruanNepali, NepaleseDutch, NetherlandicNew CaledonianNew Zealand, NZNicaraguanNigerienNigerianNiueanNorfolk IslandNorthern MariananNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New Guinean, PapuanParaguayanPeruvianPhilippine, FilipinoPitcairn IslandPolishPortuguesePuerto RicanQatariRéunionese, RéunionnaisRomanianRussianRwandanBarthélemoisSaint HelenianKittitian or NevisianSaint LucianSaint-MartinoiseSaint-Pierrais or MiquelonnaisSaint Vincentian, VincentianSamoanSammarineseSão ToméanSaudi, Saudi ArabianSenegaleseSerbianSeychelloisSierra LeoneanSingaporeanSint MaartenSlovakSlovenian, SloveneSolomon IslandSomali, SomalianSouth AfricanSouth Georgia or South Sandwich IslandsSouth SudaneseSpanishSri LankanSudaneseSurinameseSvalbardSwaziSwedishSwissSyrianChinese, TaiwaneseTajikistaniTanzanianThaiTimoreseTogoleseTokelauanTonganTrinidadian or TobagonianTunisianTurkishTurkmenTurks and Caicos IslandTuvaluanUgandanUkrainianEmirati, Emirian, EmiriBritish, UKAmericanUruguayanUzbekistani, UzbekNi-Vanuatu, VanuatuanVenezuelanVietnameseBritish Virgin IslandU.S. Virgin IslandWallis and Futuna, Wallisian or FutunanSahrawi, Sahrawian, SahraouianYemeniZambianZimbabweanAre you a British Passport holder?(Required)(please select one) Yes No Your course consultant will need to see your passport at a later stage for our records.Your course consultant will need to see your visa or right to study at a later stage for our records.Where would you like to study?(Required)(please select one) Online London 1. How did you first hear about the CNM?(Required)(please give specifics)2. If you were recommended, please give the name of the referrer3. What ‘O‘ or ‘GCSE‘ Levels do you have (please state grades)?(Required)4. What ‘A‘ Levels do you have?(Required)5. What other qualifications do you have?6. What work experience do you have (state length and qualification obtained)?(Required)7. Have you attended any other courses on Medicine, Naturopathy or Complementary Medicine?(Required) Yes No 7b. If yes, please give details8. What would you like to achieve by studying this course?(Required)REGISTRATION DETAILSPlease state how you would like to progress on your CNM study.Starting:(Required)Please indicate how you intend to finance your proposed course of study.(Required)I certify that the details given on this form are correct and I hereby apply for admission to the CNM.(Required) I certifySignature(Required)Date(Required)Today's date of applicationDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920FULL NAME (PRINTED)(Required)
