Online Request for Evaluation/ Application For Enrollment
Fax copies of transcripts or copy of most recent Diploma to
318-688-2148
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| First Name |
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| Middle Name |
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| Last Name |
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| Maiden Name |
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| Address |
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| City |
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| State |
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| Country |
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| Zip |
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| E-Mail Address |
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| Phone |
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| Cell Phone |
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| Employer |
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| Work Phone |
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| Occupation |
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| Sex |
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Birth Date
(mm-dd-yyyy) |
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Previous Education Information |
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| Colleges/Universities Attended |
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First College/Univ. Attended |
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First College/Univ. Degree Earned |
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Second College/Univer. Attended |
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Second College/Univ. Degree Earned |
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Third College/Univ. Attended |
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Third College/Univ. Degree Earned |
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Fourth College/Univ. Attended |
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Fourth College/Univ. Degree Earned |
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What degree do you intend to pursue? |
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| Three types of course delivery to select from (check one) |
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Request for Life Credit |
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Life Credit in Religious Studies
Name of Churches you have attended or served.
Number of years.
Positions and Duties
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Life Credit in Christian Education
Name of Institutions.
Number of Years
Positions & Duties
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Life Credit in Counseling
Name of Institutions.
Number of Years
Positions & Duties
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Life Credit in Communications
Name of Institutions.
Number of Years
Positions & Duties
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Life Credit in Non-College Training
Name of Course,
Provider,
Subject and Materials Covered,
Location,
Date and Clock Hours
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Life Credit in Non-College Training
Name of Course,
Provider,
Subject and Materials Covered,
Location,
Date and Clock Hours
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Life Credit in Non-College Training
Name of Course,
Provider,
Subject and Materials Covered,
Location,
Date and Clock Hours
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Life Credit in Non-College Training
Name of Course,
Provider,
Subject and Materials Covered,
Location,
Date and Clock Hours
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References
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Reference One:
In the provided area to the right give the following:
Name:
Address:
City/ST/Zip:
Phone Number:
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Reference Two:
In the provided area to the right give the following:
Name:
Address:
City/ST/Zip:
Phone Number:
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Reference Three:
In the provided area to the right give the following:
Name:
Address:
City/ST/Zip:
Phone Number: |
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Fax copies of transcripts or copy of most recent Diploma to
318-688-2148 |
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