Application For Residency Training

Contact Information
What are you applying for?*
- Residency Week And Full Certification
- Audit Residency
Select Residency Week:*
- April 8-12, 2019 - Flower Mound, TX
- June 24-28, 2019 - Hampton, Georgia
Name*
First Last
Address*
Street Address City State ZIP Code
Cell Phone*
Home Phone
Work Phone
Email*
Gender
- Male
- Female
Age*
DOB*
mm/dd/yyyy
Spiritual History
Church Home:*
Denomination*
Education
Year Graduation From High School:*
Highest level of college completed:
Post graduate degree(s):
Criminal History
Have you ever been convicted of a felony?*
- No
- Yes
Questionnaire
Provide your testimony in regard to receiving Jesus Christ as your Lord and Savior and describe your relationship with Jesus Christ.*
Do you currently have any formal training or experience in counseling?*
Why do you want to be a counselor?*
Please describe your relationship with your home church?*
How did you learn about our program?*
Agreement and Signature
By submitting this application, I affirm that the facts set forth in it are true and complete.
Printed Name
Date*
Signature*

No payment is due at the time of the application. You will be invoiced for the deposit amount.

Contact Information
What are you applying for?*
- Residency Week And Full Certification
- Audit Residency
Select Residency Week:*
- April 8-12, 2019 - Flower Mound, TX
- June 24-28, 2019 - Hampton, Georgia
Name*
First Last
Address*
Street Address City State ZIP Code
Cell Phone*
Home Phone
Work Phone
Email*
Gender
- Male
- Female
Age*
DOB*
mm/dd/yyyy
Spiritual History
Church Home:*
Denomination*
Education
Year Graduation From High School:*
Highest level of college completed:
Post graduate degree(s):
Criminal History
Have you ever been convicted of a felony?*
- No
- Yes
Questionnaire
Provide your testimony in regard to receiving Jesus Christ as your Lord and Savior and describe your relationship with Jesus Christ.*
Do you currently have any formal training or experience in counseling?*
Why do you want to be a counselor?*
Please describe your relationship with your home church?*
How did you learn about our program?*
Agreement and Signature
By submitting this application, I affirm that the facts set forth in it are true and complete.
Printed Name
Date*
Signature*

No payment is due at the time of the application. You will be invoiced for the deposit amount.

APPLICATION