Acupuncture Board - Application for Tutorial Supervisor

ACUPUNCTURE BOARD rd444 North 3 Street, Suite 260, Sacramento, CA 95814 Phone: (916) 445-3021 Fax: (916) 445-3015 www.acupuncture.ca.gov Application for Tutorial Supervisor Tutorial Program [Please print or type] Name ________________________________________________ License No. _____________________ Last First M.I. Address________________________________________________________________________________ Telephone ( ) _______________; Fax No. ( ) _________________; E-mail_____________________ Name of Clinic (where training will be provided): _____________________________________________ Address of clinic: ________________________________________________________________________ Proposed Trainee’s Name _________________________________________________________________ Last First M.I. Proposed Starting Date of Tutorial Program ___________________ Ending Date__________________ [Please note that the starting date must be at least 30 days from the date the application was mailed to the Acupuncture Board.] Do you have ten (10) years of licensed acupuncture experience? No Yes If yes, please provide the dates of experience - From ________________ To__________________ Resume: Attach either (a) Resume, or (b) a summary of professional training, education, and experience ...