Southeast Student Application

Date

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.

Upload Photo Here

Date of Birth

Date

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

Upload passport here

Do you have a visa to enter the United States?

Please upload a picture of your United States visa

Upload visa here

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

Date

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

By entering your name here, you agree that your application has been faithfully completed.

Signature

Date

The information contained in this application is correct to the best of my knowledge. I hearby authorize Southeast Institute of Biblical Studies and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. 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 further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to Southeast Institute of Biblical Studies or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.

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

Southeast Student Application

Release to Obtain Background Check