Southeast Student Application

Southeast Student Application
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Full Name

First NameMiddle NameLast NameSuffix
I want to begin classes
Intended Start Date
Year
Please provide a recent photo of yourself and your family if you are married. Please limit the photo to 250k.

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Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Place of Birth
Is English your first language?
Are you a United States citizen?
Are you in the United States legally?
What is your country of citizenship?
Passport Number
Please upload a picture of your passport

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Do you have a visa to enter the United States?
Please upload a picture of your United States visa

Upload visa here
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Social Security Number
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone Number
Format: (000) 000-0000.
Email
example@example.com
Are you available for an in-person interview?
Current Congregation
Congregation Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Congregation Phone Number
Format: (000) 000-0000.
Where are the areas where you have served in the church?
Preacher's Name

First NameLast Name
Preacher's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Elder/Member Name

First NameLast Name
Elder/Member Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
When were you baptized?
Marital Status
If you have been divorced and are remarried, please explain your situation in sufficient detail.
How long have you been married?
Wife's name

First NameLast Name
Wife's Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please list the names and ages of your children.
Have you been employed during the last 3 years?
Type of employment for the last 3 years?
May we contact your employer for a reference?
Employer's Name

First NameLast Name
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Have you ever served in the military?
If so, were you honorably discharged?
Are you qualified to receive V.A. educational benefits?
Can you fully support yourself while at SEIBS without assistance?
Will you need to raise support during your time at SEIBS?
Please provide the name, address, phone number, and email address of three church leaders who have known you for the past three years or since you have become a Christian to serve as a reference for you.
Reference 1
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Relationship to me:
Elder, Preacher, etc...
Reference 2
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Relationship to me:
Elder, Preacher, etc...
Reference 3
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Relationship to me:
Elder, Preacher, etc...
Do you have a high school diploma or GED?
Have you had to withdraw from any school or college?
List high schools and colleges you have attended as well as the years you attended
List any previous college degrees earned
List any history of health problems (physical or emotional) and mediations you take as treatment
Have you been hospitalized for these medical problems (physical or emotional)?
Please note: Answering yes to the following questions DOES NOT EXCLUDE you from consideration for acceptance.
Do you use any addictive substances? (alcohol, tobacco, vape, pharmaceuticals not used as prescribed, street drugs, etc)
If yes, please explain.
Have you been through a formal rehabilitation program?
If yes, which program?
If you answered yes to this question, please provide the name, address, and phone number of the physician or professional counselor who worked with you in this area.
Do you have any physical handicap that might challenge you as a student?
If yes, what type and when?
Have you ever been diagnosed with a learning disability or challenge?
Is yes, what type and when?
Have you ever been convicted of any violation of the law (minor traffic violations excepted)?
If yes, please explain.
Conduct Agreement
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Release to Obtain Background Check

I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions, driving records, birth records, and any other public records.I hearby release Southeast Institute of Biblical Studies, the Social Security Administration, and its agents, officials, representative, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: