Name (Last):    A value is required.      Name (First):    A value is required.      MI:   

     Address 1:    A value is required.      Address 2:   

     City:    A value is required.      State:   A value is required.      Zip:   A value is required.Invalid format.     

   Email:   A value is required.Invalid format.      Alternate Email:   

     Phone (Home):    A value is required.      Phone (Cell):   

     Phone (Work):          Fax:   

     Marital Status:          Spouse's Name:   

Background Application

     Present Occupation:   

     How Long Have You Held This Position?:   

     Employer:   

     Address 1:           Address 2:   

     City:          State:          Zip:   

     How Many Years Have You Been A Christian?:  

     Year Graduated High School:   

      Year Graduated College:   

     Name of Academic Institution:   

     Are You An Ordained Minister?:             Year Ordained:   

     Your Denominational Preference:  

     Name of Local Church:   

     Pastor's Name:   

     Pastor's Address:

     Address 1:           Address 2:   

     City:          State:          Zip:   

     Friend or Relative's Name:   

     Friend or Relative's Address:

     Address 1:           Address 2:   

     City:          State:          Zip:   

     How did you hear about Abundant Life Christian Counseling Services / National Christian Counselors Association?:     

       

Payment Information

      I am enclosing the $100 application fee for the Certified Pastoral Counselor Program.

      I am enclosing the $100 application fee for the Certified Temperament Counselor Program.

      I am enclosing the $100 application fee for the B.A. Degree Program.

      I am enclosing the $200 application fee for the Masters Program.

      I am enclosing the $300 application fee for the Ph.D. Program.

     Type of Payment:

      MasterCard

      Visa

     Name (exactly as on card):    A value is required.

     Card #:   A value is required.       Expiration date:   A value is required.

     CW2 Code (on back of card):   A value is required.Invalid format.

This application is for evaluation only and does not guarantee acceptance. The application fee is non-refundable. We will contact you to schedule an appointment to evaluate your situation and review your transcripts as applicable. If applicant is accepted, courses and tuition will be discussed and agreed upon.