Name:_______________________________________ Date:________________

Address:____________________________City_____________ST___Zip______

Home Phone (____) ______________ Other (____)____________________

Date of Birth:___/___/___ Sex: Male__ Female__

Social Security Number:_____________________________

Are you a Pastor?_____ Name of your Church:__________________________

Why do you want this education?
_______________________________________________________
_______________________________________________________
_______________________________________________________

Please list below, all colleges, universities, and seminaries attended:

School:_________________________ City & State________________ Degree______

School:_________________________ City & State________________ Degree______

School:_________________________ City & State________________ Degree______

Your application and evaluation will be processed by the Admissions Office.

Please indicate below the degree program for which you are applying.

Bachelors(X )

Applicant Signature__________________________________Date___________