Application

I. PERSONAL INFORMATION

II. Educational Information
List all high school, colleges and universities attended, beginning with the most recent. Please list the name of the institution, location, dates you enrolled, degree completed and estimated GPA.

III. Church Information

IV. Recommendations
List the names and addresses of three references: (1) a character reference; (2) your pastor or a leader in your church, and (3) a professor or professional colleague. Fill out the top of the recommendation form (see attachment above) and give it to each person.

V. I certify that the information provided in this application is true, correct, and complete. I understand that false statements in these materials or in the admissions process are grounds for denial of admission or dismissal from the certification program.

I. PERSONAL INFORMATION
Name:
Current Address:
City:
State:
Zip:
Home phone:	() -Second partThird part
Work phone:	() -Second partThird part
E-mail address:
Date of birth:
Place(s) of employment:
Full-time:
Part-time:
Approximate hours per week:
Address of employer:
Marital status:	Single Married
Name of spouse:
Name and age of children:
Do you have any court convictions, or if legal action against you is pending other than traffic violations:	Yes No
If so, please explain:
II. Educational Information List all high school, colleges and universities attended, beginning with the most recent. Please list the name of the institution, location, dates you enrolled, degree completed and estimated GPA.
College #1:
College #2:
College #3:
High school:
Have you ever been dismissed or denied admission by any seminary, divinity, or graduate school?:	Yes No
If yes, please explain:
Are you currently enrolled in a divinity school?:	Yes No
If yes, which one?:
III. Church Information
Present church membership:
Denomination:
Address of Church:
Pastor's name:
Phone number:	() -Second partThird part
Are you a licensed minister:	Yes No
Are you ordained?:	Yes No
IV. Recommendations List the names and addresses of three references: (1) a character reference; (2) your pastor or a leader in your church, and (3) a professor or professional colleague. Fill out the top of the recommendation form (see attachment above) and give it to each person.
Person #1 (include name, address and phone number):
Person #2 (include name, address and phone number):
Person #3 (include name, address and phone number):
V. I certify that the information provided in this application is true, correct, and complete. I understand that false statements in these materials or in the admissions process are grounds for denial of admission or dismissal from the certification program.
Type applicant name:
Date:

Preschool and Children Ministry Certification Application