SEIBS Student Application

Southeast Student Application
Date*

MonthDayYear
Date
Full Name*

First NameMiddle NameLast NameSuffix
I want to begin classes*

AugustJanuary
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
Date
Place of Birth*
Is English your first language?*

YesNo
Are you a United States citizen?*

YesNoOther
Are you in the United States legally?
What is your country of citizenship? *
Passport Number*
Upload a picture of your passport

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Social Security Number*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
E-mail*
Confirm E-mail
Are you available for an in-person interview?*

YesNo
Are you available for a video interview?*

YesNo
Current Congregation*
Congregation Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Congregation Phone Number*

Area CodePhone Number
What are the are areas where you have served in the church? *
Preacher's Name*

First NameLast Name
Preacher's Phone Number*

Area CodePhone Number
Elder/Member Name*

First NameLast Name
Elder/Member Phone Number*

Area CodePhone Number
When were you baptized? *
Marital Status*

Single (Never Married)DivorcedMarriedWidow
If you have been divorced and are remarried, please explain your situation in sufficient detail.
Wife's name

First NameLast Name
Wife's Birth Date

MonthDayYear
Date
Please list the names and ages of your children.
Have you been employed during the past 3 years?*

YesNo
Type of employment for the last 3 years*
May we contact your employer for a reference?*

YesNo
Employer's Name

First NameLast Name
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer's Phone Number

Area CodePhone Number
Have you ever served in the military?

YesNo
If so, were you honorably discharged?

yesNo
Are you qualified to receive V.A. educational benefits?

Yes
Can you fully support yourself while at SEIBS without assistance?

YesNO
Will you need to raise support during your time at SEIBS?

YesNO
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?*

YesNo
Have you had to withdraw from any school or college?*

YesNo
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 medications 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, pharmaceuticals not used as prescribed, street drugs, etc)*

YesNo
If yes, please explain.
Have you been through a formal rehabilitation program?*

YesNo
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?

YesNo
If yes, what type and when?
Have you ever been diagnosed with a learning disability or challenge?*

YesNo
If yes, what type and when?
Have you ever been convicted of any violation of the law (minor traffic violations excepted)?*

YesNo
Conduct Agreement*

I will abide by all rules and regulations of SEIBS.I will maintain the highest moral, spiritual, and academic standards.I will, to the best of my ability, participate in all activities of SEIBS and the Karns congregation.I will do my best to complete all school work assigned.I will attend the services of the Karns church of Christ unless obligated elsewhere.
By entering your name here, you agree that your application has been faithfully completed.
E-Signature*

Clear
Click and hold to sign your name
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Southeast Student Application