Graduate Certificate Application Form

I plan to take the majority of my classes*

as a local/residential student.
as a Connections (distance) student.

Anticipated Start Date*

Name of Certificate*

Certificate of Achievement in Theological Studies
Specialized Certificate in Intercultural Biblical Interpretation
Specialized Certificate in Just Peace and Conflict Transformation
Specialized Certificate in Theopoetics and Theological Imagination
Specialized Certificate in Theology and Science

Personal Information

Name*

First Middle Last

Address*

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

Phone*

E-mail*

Gender

Date of Birth*

Social Security Number

Demographic Information

Race/Ethnic Group

Place of Birth

Current Career

Marital Status

Household Members

Religious Affiliation

Faith Tradition

Congregation

If Church of the Brethren, your district

Ministerial Status (e.g. licensed, ordained)

Year of Ordination/Licensure

Ordaining/Licensing District or Judicatory

Educational Preparation

Highest Level of Education Experience*

Please list colleges, universities, and seminaries attended and/or other ministry training programs in which you have participated, beginning with the most recent.

Some college work
Bachelor's degree
Some graduate work
Graduate degree

Educational Institution #1*

Address*

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

Dates Attended*

Degree Achieved (if applicable)*

Educational Institution #2

Address

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

Dates Attended

Degree Achieved (if applicable)

Educational Institution #3

Address

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

Dates Attended

Degree Achieved (if applicable)

Additional Space (if needed)

Background Information

If you answer yes to any of these questions, please explain in the space provided.

Have you ever been disciplined by a judicatory body responsible for ministerial ethics?*

Yes
No

Explanation

AFFIRMATION

By clicking "Submit," I hereby affirm that all the information contained in this application is factually correct and honestly presented. I understand that any omission or falsification of information on this application may be grounds for denial of admission or immediate dismissal. I also understand that all documents submitted for application become the property of Bethany Theological Seminary and are not returnable or transferable to any third party.

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