Revised 12-07-2016
MEMPHIS THEOLOGICAL SEMINARY
Application for Admission
Drug and Alcohol Addiction Counseling Certificate ADMISSION POLICIES 1. 2. 3. 4. 5. 6. 7.
All blanks on this application form must be completed for your application to be accepted. Complete sections I and II of the two reference forms and sign them. Give the forms to the persons who will be providing references. References from members of your family are not acceptable. Submit official transcripts form each and every college, university, and graduate school you have ever attended. After your application is received, you will be interviewed by the Admissions Office. Deadlines for applications are: August 30 for Fall semester and December 30 for Spring semester. Enclose a one-time application fee of $45.00. This fee is non-refundable. Graduate credit earned in the certificate program is not valid toward a degree program at Memphis Theological Seminary. Date of Application
, 20
Date of Anticipated Enrollment—Fall / Spring Year 20 ____
PERSONAL INFORMATION Name Last
First
Middle
Present Mailing Address Street and number or box City
State
Home Phone (
Zip
E-mail address
)
Daytime Phone (
Social Security Number
)
Date of Birth
Profession
Official Name of Denomination
Name, and 2 phone numbers of emergency contact
The information in this box is required and used only for government reporting and statistical analysis. Gender Interview
Marital Status Fee
Are you (check ONE): a U.S. Citizen Other (specify citizenship):
Race Ref
Ref
a Resident Alien
Student ID
Fee
ACADEMIC BACKGROUND List fully your record of higher education, including any institution in which you are currently enrolled: Institution
Dates Attended
Signature of Applicant
Return application to:
Major Field
Degree/Date
Date In signing this application you verify that the information given is true, correct, and complete to the best of your knowledge.
Admissions Department 168 East Parkway South Memphis, TN 38104
As a matter of policy, Memphis Theological Seminary does not discriminate among applicants on the basis of race, creed, gender, ethnic origin, or disability.
REFERENCE FORM
MEMPHIS THEOLOCIGAL SEMINARY I. REQUEST (to be completed by applicant) This form is to serve as my reference. _____________________________ has applied for admission to Memphis Theological Seminary for the Fall / Spring term, 20___, to pursue a Certificate in Drug and Alcohol Addiction Counseling, and has given your name as a reference. We would appreciate your careful, candid, and complete assessment of the applicant. Please note whether the applicant has or has not waived the right to access this document.
II. WAIVER (to be completed by applicant) I, the undersigned, waive
do not waive my right of access to this document.
Signature ______________________ Date ______________ III. EVALUATION (to be completed by person providing recommendation) You are asked to rate the applicant on the following characteristics, qualities, and attitudes. On a scale of five, five is the highest rating and one is the lowest. Check the appropriate box. If you have insufficient knowledge of the person for a rating on a given item, check IK.
5 Performance of assignments and tasks Moral Integrity Leadership ability Cooperative attitude Spiritual Maturity Academic abilities Creativity Thoughtfulness of others An inquiring mind Acceptance of guidance Self-confidence Ability to handle stress Potential for graduate/professional study (over)
4
3
2
1
IK
IV. ADDITIONAL COMMENTS (to be completed by person providing recommendation) 1. Please comment on the applicant’s suitability for and promise as a student.
2. How would you characterize the applicant as to emotional maturity and stability?
3. What is your assessment of the applicant’s religious orientation and experience in the life of the church?
4. Comment on any problems, limitations, or handicaps, or other factors which might adversely affect the applicant’s performance as a student at Memphis Theological Seminary.
Signature _______________________
Date _____________
IV. Personal Information (to be completed by person providing recommendation) Please print or type
Return to:
Your name
______________________________________
Your address
______________________________________
City, State, Zip
______________________________________
Daytime Phone
(____)________________________________
Your occupation
______________________________________
Your employer
______________________________________
Admissions Office Memphis Theological Seminary 168 East Parkway South Memphis, TN 38104-4395
If you have any questions, please contact the Office of Admissions at (901) 334-5804
REFERENCE FORM
MEMPHIS THEOLOCIGAL SEMINARY I. REQUEST (to be completed by applicant) This form is to serve as my reference. _____________________________ has applied for admission to Memphis Theological Seminary for the Fall / Spring term, 20___, to pursue a Certificate in Drug and Alcohol Addiction Counseling, and has given your name as a reference. We would appreciate your careful, candid, and complete assessment of the applicant. Please note whether the applicant has or has not waived the right to access this document.
II. WAIVER (to be completed by applicant) I, the undersigned, waive
do not waive my right of access to this document.
Signature ______________________ Date ______________ III. EVALUATION (to be completed by person providing recommendation) You are asked to rate the applicant on the following characteristics, qualities, and attitudes. On a scale of five, five is the highest rating and one is the lowest. Check the appropriate box. If you have insufficient knowledge of the person for a rating on a given item, check IK.
5 Performance of assignments and tasks Moral Integrity Leadership ability Cooperative attitude Spiritual Maturity Academic abilities Creativity Thoughtfulness of others An inquiring mind Acceptance of guidance Self-confidence Ability to handle stress Potential for graduate/professional study (over)
4
3
2
1
IK
IV. ADDITIONAL COMMENTS (to be completed by person providing recommendation) 1. Please comment on the applicant’s suitability for and promise as a student.
2. How would you characterize the applicant as to emotional maturity and stability?
3. What is your assessment of the applicant’s religious orientation and experience in the life of the church?
4. Comment on any problems, limitations, or handicaps, or other factors which might adversely affect the applicant’s performance as a student at Memphis Theological Seminary.
Signature _______________________
Date _____________
IV. Personal Information (to be completed by person providing recommendation) Please print or type
Return to:
Your name
______________________________________
Your address
______________________________________
City, State, Zip
______________________________________
Daytime Phone
(____)________________________________
Your occupation
______________________________________
Your employer
______________________________________
Admissions Office Memphis Theological Seminary 168 East Parkway South Memphis, TN 38104-4395
If you have any questions, please contact the Office of Admissions at (901) 334-5804
