Brethren Academy Registration/Payment Form Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*E-mail* Be sure to check your e-mail address for accuracy. We will use this address for sending your registration confirmation as well as login instructions if you are attending online.Registration InformationSelect the purpose of your payment.*Yearly TRIM Student Fee = $210Academy Course Fee = $295Directed Independent Study = $100TRIM/EFSM Program Student Enrollment Fee = $360Select your registration preference.*TRIM CreditEFSM CreditTwo Continuing Education UnitsPersonal EnrichmentEnter the name of the Academy course for which you are registering.*PaymentPayment Method*I would like to pay by credit card now.I will send a check to the Brethren Academy.If you are sending a check, please be sure to make a note of the fee amount before submitting this form.Please make your check payable to and mail to Brethren Academy 615 National Road W Richmond, IN 47374 Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name Submission ConfirmationIf you do not receive an auto-reply confirmation shortly, please notify us at email@example.com.After clicking the submit button you will receive instructions on how to send your payment to Bethany Theological Seminary.