Acupuncture for Pain
AC63-200 Application Form

Bolger Center, Potomac, MD
Introductory Weekend: 15-19 March 2018
Clinical 1: 13-17 July 2018
Clinical 2: 5-9 September 2018

In addition to completing this form, the following documents are required for your application to be considered. You must submit them via email to mafp@hmieducation.com:

The fields indicated with an asterisk (*) are required.

Name and Professional Information
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Sex:*
Date of birth:* / /
mm / dd / yyyy

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Contact Information
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Military personnel and government employees must list a non-work email address for their primary email.
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Home address:

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Street address only, no P.O. boxes.
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Please use the format 555-555-555 for US phone numbers.
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Please use the format 555-555-5555 for US phone numbers.
Military Personnel & Government Employee Applicants Only
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Date of end of obligated service: /
mm / yyyy
Tuition*
  • ($10,500 after 15 February 2018; $250 discount if paid by check)
  • ($9,500 after 15 February 2018; $250 discount with check)
    Applicant must be a full-time resident or fellow through the conclusion of the course and pay his/her own tuition.

Indicate method of payment:*

  • (preferred), payable to Helms Medical Institute, 2520 Milvia Street, Berkeley, CA 94704
  • , pay online at https://mkt.com/hmi
  • , call 510-649-8488 between 8:30 AM and 12:30 PM Pacific Time or fax to 510-649-8692
  • , specify:
Supplemental Materials

The following documents are required to process your application:

  • Résumé / CV
  • Photocopy or scan of your current medical license
  • Statement of plans (Military applicants: In your statement, please confirm your base command's endorsement of your training and an acupuncture-friendly clinical setting.)
  • Tuition payment (unless the tuition is funded through a 3rd party)

Your personal check will not be deposited until you have been accepted to the course.

Once you have submitted this online application you will receive a confirmation email. Reply to this email with the above documents as attachments. Be sure to add hmieducation.com to your approved sender list.

All training activities will take place at Bolger Center, Potomac, MD. You are requested to lodge at the hotel where a group rate has been arranged. A conference day use fee of $75 per day is required of participants who choose to stay elsewhere or room with another course participant. For additional information about this course, call 510-649-8488 or e-mail mafp@hmieducation.com.