PITAHC

Philippine Institute of Traditional and Alternative Health CarePITAHC Bldg., Matapang St., East Ave. Medical Center Cmpd., Diliman, Q.C.

Telephone Numbers: (02) 376-3067 / 496-9676

APPLICATION FOR ACUPUNCTURE TRAINING PROGRAM REGISTRATION AND TRAINING CENTER ACCREDITATION

______________________Date

The Director GeneralPhilippine Institute of Traditional and Alternative Health CarePITAHC Bldg., Matapang St., East Ave., Medical Center CompoundDiliman, Quezon City

Thru : Social Advocacy and Training / Standard and Accreditation Division

Sir/Madam:

The undersigned, _____________________________, _________________________ of the(Head of Institution) (Position/Designation)

___________________________, a _____________________________________ located at(Name of School/Institution) (Type of School/Institution)

_________________________________________________, hereby petition for registration (Complete Address)

of the Acupuncture Training course and accreditation of Training Center under the PITAHC Guidelines:

Course(s)/Program(s) Duration____________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ ______________________

To support this petition are the following documents duly certified/authenticated:

A) Corporate and Administrative Papers1. Notarized Letter of Application2. Certified Board Resolution (Private Institution only)3. SEC Registration and Articles of Incorporation (Private Institution only)4. Fire Safety Inspection Certificate5. Proof of ownership of the Training Center’s premises or lease-contract of at least five years6. Municipal or City permits (including Sanitary Permit)

B) Curricula Requirements1. Curriculum (Indicating the Job Title (s) being address and the competency standard)2. Course and Subjects Description (Include course objectives, no of hours for didactic

and practicum)3. List of Supplies, Tools and Equipment for the Training Program(s) (indicating the

quantity, specification, and date of purchase)4. List of Instructional Materials (Books, Video Tapes, CDs, Internet Access, etc.)

C) Faculty and Personnel (with supporting papers)1. List of School Officials and their Qualifications2. List of Faculty for the Program (Indicating their Qualifications, Teaching

Assignment, Status of Appointment with supporting documents, for example: Trainers’ Profile, Transcript of Records, Certifications, etc.)

3. List of Non-teaching Personnel and their Qualifications4. Valid Health Certificate of all personnel/staff

D) Academic Rules1. Schedule of Tuition and Other Fees2. Grading System3. Entrance Requirements4. Rules on Attendance

E) Support Services1. Health Services2. Career Guidance/Placement Services3. Community Outreach Program4. Research Program

(Note: Submit the abovementioned requirements in seven (7) copies, I original copy)

I. ______________________________, as ______________________________, promise to(Head of Institution) (Position /Designation)

maintain the standards required for the training courses/program and accreditation requirements to follow faithfully all laws, rules and regulations of the Philippine Institute of Traditional and Alternative Health Care (PITAHC) governing the said operations and/ or any changes in the prescribed requirements. I acknowledge that the violation of the authority granted.

The institution will not conduct classes in the above course(s)/program(s) applied for until and unless this application is approved and the PITAHC authority issues the corresponding certificate.

Very truly yours,

______________________________(Signature over Printed Name)

A F F I D A V I T

Republic of the PhilippinesCity/Municipality of ______________) s.sProvince _______________________)

I,______________________________ , of ____________________________, Filipino, of legal age, and a resident of the Philippines, after having been sworn to in accordance with laws, depose and that the information in this application and in the supporting documents are true and correct.

SUBSCRIBED AND SWORN To before me this ____ day of _____________________ _______. The affiant exhibit his/her Community Tax Certificate No._______________ issued at _____________________ on ______________.

_____________________________Notary Public

Doc. No: __________Page No: __________Book No: __________Series of: __________