Date of Application *

MM

DD

YYYY

Date Training Begins *

MM

DD

YYYY

Status of Student *

Full-Time

Part-Time

Projected Date of Completion *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Gender *

Female

Male

Married Status *

Single

Married

Separated

Divorced

Widowed

Ethnicity *

White

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

High School Diploma - Year *

MM

DD

YYYY

GED Equivalency - Year *

MM

DD

YYYY

College Graduate - Year *

MM

DD

YYYY

Graduate School - Year *

MM

DD

YYYY

Employer's Phone Number *

(###)

###

####

Employer Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I will be studying through: *

Internet

Distance Learning Cent (DLC)

Date I plan to begin my first CIMS course: *

MM

DD

YYYY

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I, the student, have read and understand this document. *

For the program entitled Certificate In Ministerial Studies (CIMS), I have been informed that for the July 1, 2018–June 30, 2019 period, the withdrawal rate is .086%, the completion rate is .007%, and the in-field placement rate is .007%. Detailed statistical data for this program may be viewed by going to http://state.tn.us/thec and clicking on the “Authorized Institutions Data” button. Sign below, with the following affirmation: “I do hereby affirm that I have retained a personal copy of this Enrollment agreement to the Church of God School of Ministry, which details the total cost of the program and the refund policy.”

yes