Enrollment Reservation and Deposit

Personal Information

Name*

First Last

Complete Mailing Address:*

(If you will be relocating to Richmond, please submit a change of address form with the Enrollment and Financial Aid Assistant when you arrive.)

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

Phone:*

Email:*

Photo:*

Upload photo
Permission to use a photo from my Facebook profile

Upload a photo:*

Accepted file types: jpg, jpeg, png, pdf, webp, Max. file size: 50 MB.

Facebook Username URL:*

To learn how to find your Facebook Username URL, please visit: Facebook Help

Additional Information

I plan to enroll beginning:*

August intensive
Fall semester
January intensive
Spring semester
May intensive

Student Directory:*

I authorize Bethany Theological Seminary to include my name and address in the student directory.
I do not authorize Bethany Theological Seminary to include my name and address in the student directory.

Student Mailbox:*

I would like a student mailbox at the Richmond Campus.
I do not want a student mailbox at the Richmond Campus.

Billing Statement:*

I prefer to receive my billing statements via U.S. Mail
I prefer to receive my billing statements in my student mailbox on campus.

Payment

Product Name

Enrollment Deposit

$0.00

Payment Method*

I would like to pay by credit card now.
I will send a check to Bethany.

Credit Card*

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

After clicking the submit button, you will receive instructions on how to send your payment to Bethany Theological Seminary.

Understanding

By signing below, I understand that submission of this form and its accompanying deposit will 1) hold my place in the entering class (or as a transfer student), and 2) secure my financial aid award, if any. I realize that failure to submit the deposit or this form will prevent my ability to register for classes. I also understand that the deposit is non-refundable.

E-Signature:*

Please type your name.

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