First Name

Middle Name

Last Name

Date of Birth

E-mail Address

Mailing Address

City

State

     Zip 

Phone Number

Social Security Number

Tribe (if applicable)

Census #

Marital Status

Please Select OneSingleMarriedSeperatedDivorcedWidowed 

If married,
Name of Spouse

Name and ages 

of children

Have you used 

any of the following 

in the last five years:

Drugs?

Alcohol?

Tobacco?

  Yes       No

  Yes       No

If you checked yes on one of the above, please explain.

Do you have any illness or physical problem that may interfere with your regular attendance in school?

  Yes         No

If yes, please explain.

Education
 

List high school graduated from and any colleges attended: 

Name of high school

Location

Dates attended

  Date Graduated

Name of school

Location

Dates attended

  Date Graduated

Name of school

Location

Dates attended

  Date Graduated

Name of school

Location

Dates attended

 Date Graduated

Other Schools or Colleges
 

If you have not graduated from high school, have you completed the GED exam?

  Yes         No    
If yes, date of GED
 

Special Note: 

Please request that your high school & college transcripts be sent to the Registrar at the following address.

Attn: Registrar
Indian Bible College
PO Box 30880
Flagstaff, AZ 86003-0880
 

Your Local Church

Name of the church you attend:

Church Address

City

State

     Zip 

Are you a member 

of the church? 

  Yes          No

Pastor's Name

Pastor's Address

City

State

     Zip 

Please tell us about any role in which you participate in church?

Please select oneBoard MemberSunday School TeacherMusic Director TreasurerOther 

If other, please specify:

Pastor or Missionary

1.

Name

Telephone

Address

City

State

     Zip 

2.

Name

Telephone

Address

City

State

     Zip 

3.

Name

Telephone

Address

City

State

     Zip 

4.

Name

Telephone

Address

City

State

     Zip