Personal Information

Application Deadlines:

Fall - July 15

Spring, Winter Intensive - December 1

Summer, Summer Intensive - May 1

Name*

First Middle Last Maiden

Current Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Address*

Mobile Phone*

Home Phone

Work Phone

Marital Status*

Single

Married

Divorced

Date of Birth*

If you answer “yes” to any of these questions, please provide appropriate details in the space provided and/or submit relevant documentation.

Do you have any physical, mental, or emotional disabilities which may require special assistance?*

If yes, please elaborate.*

Do you have learning disabilities or mental/physical condition(s) that might affect your academic work?*

If yes, please elaborate.*

Have you ever been under the care of a psychologist, mental health counselor, or psychiatrist?*

If yes, please elaborate.*

Will you incur debt by attending Desert Hills Bible Institute?*

If yes, provide your plans for financing your theological education.*

Have you ever been dismissed, placed on academic, or disciplinary probation, or asked to withdraw by any educational institution?*

If yes, please elaborate.*

Have you ever been convicted of any felony or been dishonorably discharged from any branch of the Armed Services?*

If yes, please elaborate.*

Have you ever been dismissed, terminated, or fired from any place of employment?*

If yes, please elaborate.*

Have you ever used illegal drugs or abused alcohol?*

If yes, please elaborate.*

Have you ever appeared on a local, state or national sex offender registry?*

If yes, please elaborate.*

Have you or your spouse ever been divorced?*

If yes, please elaborate.*

Have you ever been involved in any sexual misconduct of any nature from which you have not repented and been biblically restored by your church?*

If yes, please elaborate.*

Family Information

Spouse's Name

First Middle Last N/A

Children

First Name

Middle Name

Last Name

Emergency Contact Name*

First Last

Relation of Emergency Contact*

Emergency Contact Phone Number*

Employment Information

Please list your last four employers starting with the most recent.

How many employers have you worked for?*

Employer 1*

Supervisor 1*

First Last

Supervisor 1 Phone Number*

Position Held 1*

Start Date 1*

Are you currently working here?*

Yes

No

End Date 1*

Employer 2*

Supervisor 2*

First Last

Supervisor 2 Phone Number*

Position Held 2*

Start Date 2*

End Date 2*

Employer 3*

Supervisor 3*

First Last

Supervisor 3 Phone Number*

Position Held 3*

Start Date 3*

End Date 3*

Employer 4*

Supervisor 4*

First Last

Supervisor 4 Phone Number*

Position Held 4*

Start Date 4*

End Date 4*

Church Information

Current Church Membership*

Member in good standing

Attendee

Not attending a church

Name of Church*

Church Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Church Email Address*

Church Phone Number*

Church Lead Pastor*

Member Since*

Education Information

Name of High School*

State*

High School Start Date*

High School End Date*

High School Credential Conferred*

How Many Colleges/Institutions Did You Attend?*