BASIC INSTITUTE REGISTRATION INFORMATION FORM (Please Print) God has a wonderful purpose for your life. We want to help you find and fulfill that purpose. The following information will enable us to do that more effectively. Please fill out the form as completely as possible. DATE______________________ NAME _____________________________________________________________________ Last First Middle Nickname ADDRESS ___________________________________________________________________ CITY __________________________________ STATE _______________ ZIP ____________ COUNTRY ___________________________________________ PHONE: HOME PHONE ______________________ WORK PHONE ______________________ CELL PHONE _____________________ BEEPER __________________________ FAX __________________________________________ EMAIL ________________________________________ MALE __ FEMALE __ BIRTH DATE ________ AGE ________ MARITAL STATUS: SINGLE__ MARRIED__ SEP.___ DIV.___ If married give spouse's name _______________________ Spouse should also submit an application if they desires to study. Children ____ Give names, gender, and ages: __________________________________________________________________________ EDUCATION List your education (secular and religious) beginning with highest degree. Be sure to include any discipleship or ministry training you've had through churches or ministries. School School Address Degree Earned Date __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ WORK EXPERIENCE: Beginning with latest job, be sure and include ministry experience. Date Employer Employer's Address Position held __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Give three Christian references: (your pastor and two others) Name Address Years Known __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ List special skills you have (sewing, cooking, carpentry, plumbing, etc.) __________________________________________________________________________ Why do you wish to study at BASIC Institute? __________________________________________________________________________ TRAINING DESIRED: __________________________________________________________ Do you have access to: __ an audio cassette or ___ CD player (If you do not have access to a player, you will only receive the manuals.) Do you have access to a computer __ yes __ no If yes, what word processing program does it use. ________________________________ We would like to get to know you better. Please enclose a copy of your personal testimony in 500 words or less, telling of your life before you were saved, how you found Jesus, and your life as a Christian. Also, please also tell us if you are a member of, or fellowship with, a church in your area. Note: BASIC Institute does not discriminate on the basis of race or national origin. MAIL TO: BASIC Institute P.O. Box 431 Kiln, MS 39556 USA 1