LIFE CENTER OF BRANDON
720 W. Robertson St. Brandon, FL 33511
(813) 322-3860 office (813) 322-3944 fax
EXTENSION SCHOOL REGISTRATION FORM
Print or Type Clearly
DATE_____/______/______
TITLE: Rev. Pastor Mr. Mrs. Ms. Other:____________
LAST NAME ______________________________________
FIRST NAME______________________________________
MIDDLE NAME____________________________________
PHONE (_________)________________________________
MAILING ADDRESS___________________________________________
CITY_________________________ STATE ________ ZIP___________
COUNTRY_________________
BIRTH DATE _____/_____/_____ E-MAIL ADDRESS_____________________________
HOME CHURCH _______________________________________________
ADDRESS________________________________________________________________
PASTOR'S NAME ________________________ OFFICE PHONE ( )________________
STUDENT INFORMATION:
1) Are you born again?____ Date: ____/____/____ Are you Spirit filled according to
Acts 2:4?______
2) Do you intend your studies to prepare you as a Minister____ or Church Leader ____?
3) Are you called to the Ministry?____ Are you currently engaged in the Ministry?____
If yes, attach a resume detailing all ministerial work.
PREVIOUS EDUCATION/STUDIES:
1) Attach separate college transcripts, resumes, records and/or other evidence of previous
study for Bible/Religious Education and/or secular education.
COURSE YOU ARE APPLYING FOR:
Extension School Diploma Course
Signature______________________________________ Date__________________
|