Application

* indicates required field

1. Your Name:*

2. Mailing Address:*

3. City/Town/Village/Island and Country:*

4. Phone Number:*

5. Email Address:*

6. When addressed informally, what name do you prefer? (first name, middle name, nickname, initials, etc.):*

7. Birthdate:*

8. Sex:*

Male Female

9. Age:*

10. Citizenship:*

11. Race:*

12. Marital Status:*

Single Married Divorced Separated Widowed

If you or your spouse have ever been divorced, please explain your situation here:

13. If married, name of mate (if none, enter "none"):*

14. Names and ages of children (if none, enter "none"):*

15. Do you use tobacco, alcohol, or other drugs in any form?:*

Yes No

16. If you are using tobacco, alcohol, or other drugs, would you be willing to stop using them?:*

Yes No Does not apply

17. Explain your reason for entering this training program:*

18. Proposed date of enrollment:*

19. When and where were you baptized?:*

20. Name and address of congregation you attend:*

If there is anything in your life or background of importance or significance which you feel the administration of PIBC should know, please tell us here:

Additional Information: