APPLICATION Contact InformationSelect Residency Week:*April 8-12, 2019Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Home PhoneWork PhoneEmail* GenderMaleFemaleAge*DOB*mm/dd/yyyySpiritual HistoryChurch Home:*Denomination*EducationYear Graduation From High School:*Highest level of college completed:Post graduate degree(s):Criminal HistoryHave you ever been convicted of a felony?*NoYesQuestionnaireProvide 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?*Agreement and SignatureBy submitting this application, I affirm that the facts set forth in it are true and complete.Printed NameDate* Signature* No payment is due at the time of the application. You will be invoiced for the deposit amount.