Graduate Certificate Application Form In order to complete this application form, you will need your personal information; and a list of your postsecondary education. Please note: This form cannot be saved and returned to later. I plan to take the majority of my classes*as a local/residential student.as a Connections (distance) student.Anticipated Start Date*August Intensive 2017Fall 2017January Intensive 2018Spring 2018August Intensive 2018Fall 2018Name of Certificate*Certificate of Achievement in Theological StudiesSpecialized Certificate in Biblical InterpretationSpecialized Certificate in Conflict TransformationSpecialized Certificate in Theopoetics and Theological ImaginationPersonal InformationName* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*E-mail* GenderDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Demographic InformationRace/Ethnic GroupPlace of BirthCurrent CareerMarital StatusHousehold MembersReligious AffiliationFaith TraditionCongregationIf Church of the Brethren, your districtMinisterial Status (e.g. licensed, ordained)Year of Ordination/LicensureOrdaining/Licensing District or JudicatoryEducational PreparationHighest 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 workBachelor's degreeSome graduate workGraduate degreeEducational Institution #1*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Dates Attended*Degree Achieved (if applicable)*Educational Institution #2Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Dates AttendedDegree Achieved (if applicable)Educational Institution #3Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Dates AttendedDegree Achieved (if applicable)Additional Space (if needed)Background InformationIf 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?*YesNoExplanationAFFIRMATIONBy 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. This iframe contains the logic required to handle Ajax powered Gravity Forms.