CBC REGISTRATION FORM
CHRISTIAN BIBLE COLLEGE OF LOUISIANA
REGISTRATION FORM
Campus Requested
New Orleans
Ville Platte
Online
Other Cohort
Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
-
Country Code
-
Area Code
Phone Number
Home Phone
-
Country Code
-
Area Code
Phone Number
Employer Name
Work Phone
-
Country Code
-
Area Code
Phone Number
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Place of Birth
*
Social Security Number (Required)
*
High School Attended
HS City/State
Did You Graduate?
Yes
No
If Yes, Year you graduated?
Highest Grade/Level Completed
1st - 5th Grade
6th - 8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
GED
1-3 years of College
Grad 4 yr College
Post Grad Studies
Masters Degree or Higher
Church Name
Pastor's Name
Church Address
Church City
Church State
Church Zip
Are you in Good Standing with your Church?
*
Yes
No
Church Position Held?
Pastor
Minister
Deacon
Teacher
Layperson
Other
Desired Degree
Associate
Bachelor
Master
Marital Status
Single
Separated
Divorced
Married
Widow/Widower
Medical Limitations
Emergency Contact
First Name
Last Name
Emergency Phone Number
*
Format: (000) 000-0000.
Relation to Applicant
*
CPR Certified
Yes
No
Reference 1 Name
Reference 1 Address
Reference 1 Phone
-
Area Code
Phone Number
Reference 2 Name
Reference 2 Address
Reference 2 Phone
-
Area Code
Phone Number
Attended CBC before?
Yes
No
Year previously attended
Level Completed at CBC?
Freshman
Sophomore
Junior
Senior
Master 1
Master 2
Grad Specialist 1
Doctoral
Other
Upload a copy of your photo ID (You may take a picture with your cell phone and upload)
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Applicant Signature (Type your name)
*
Application Date
-
Month
-
Day
Year
Date
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