STUDENT ENROLLMENT APPLICATION

Spring 2015 Semester

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Please do not write in this space. (For office use only)

Date: Application Received:

Date: Application Notified:

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PLEASE READ THE FOLLOWING INFORMATION BEFORE CONTINUING

  1. Completely fill out this application. PARTIAL APPLICATIONS WILL NOT BE ACCEPTED.
  1. YOU MUST be a MEMBER of the Potter’s House Church.
  1. Submit the TYPED answers to theattached PHSOM Questionnaire (on page 5) on a separate sheet of paper. Your typed response to this PHSOM Questionnaire is mandatory.
  1. Submit a non-refundable $20.00 processing fee. If you are accepted into PHSOM, this fee will be applied towards your FALL semester tuition. Please make payments via cash, cashier’s check or money order. Make all payments payable to the Potter’s House of Dallas, Inc.
  1. Return application with attached passport size photo, processing fee and answers to the questionnaire to the PHSOM table in the lobby. (APPLICATION DEADLINE IS SUNDAY, JANUARY 11, 2015)
  1. PHSOM will contact you by email regarding the status of your application.
  1. If you are accepted as an incoming student, please be prepared to pay complete tuition for the Discipleship Semester. Weekly classes are held every Monday evening; 7- 9 pm. (January 12, 2015 – May 18, 2015).
  1. Tuition for each semester is currently $200.00. PLEASE MAKE PAYMENT BY CASH, CASHIER’S CHECKS, OR MONEY ORDERS (PAYABLE TO: THE POTTER’S HOUSE OF DALLAS, INC.)

PRINT OR TYPE ALL INFORMATION

PERSONAL DATA

1. Last Name: First Name: Middle Initial:

Home Number: Work Number:

2. Address:

City/State/Zip

Email address:

3. Date of Birth: Sex: Male ( ) Female ( )Social Security #:

4. Are you a U.S. Citizen: Yes ( )No ( ) If no, please explain:

5. Emergency contact: Relationship:

Emergency Contact’s number:

CHRISTIAN EXPERIENCE AND BACKGROUND

  1. Date and place of your conversion (salvation experience):
  1. Have you been baptized in water by immersion? Yes ( )No ( )
  1. Are you a member of the Potter’s House? Yes ( )No ( )

If so, how long have you been a member? Date/Year

Have you gained any Potter’s House (or other) non-accredited Bible teaching programs other than through the regularly scheduled Sunday & Wednesday services? Yes ( ) No ( ).

If yes, what were they?

  1. Do you regularly attend Sunday service? Yes ( )No ( )Mid-week service? Yes ( )No ( )
  1. What Christian work have you done?
  1. What is the name of your former church?
  1. What is the name of your former Pastor?
  1. What is the area of your passion in ministry?
  1. What types of activities do you enjoy?

SCHOLASTIC AND VOCATIONAL DATA

  1. Indicate the last year of high school that you successfully completed:
  1. Indicate the highest level of college that you successfully completed: Degree Earned:

If you are still attending college, please give the expected date of your graduation:

  1. Please list below, the name, address, phone number, dates attended, and degree(s) received of all Colleges or other post high school institutions, which you have attended:
  1. Have you ever been dismissed, suspended, or asked to withdraw from any school? Yes ( )No ( )

If yes, please explain the reason and circumstances on a separate sheet of paper and attach it to this form.

  1. Have you ever been refused admission to any school? Yes ( ) No ( )
  1. Have you ever been warned about or placed on academic probation for low grades? Yes ( )No ( )

If yes, please list the name, address and phone number of the school.

  1. Have you previously taken a segment(s) of the PHSOM program? Yes ( )No ( )

If yes, which one:

  1. Do you have ministerial credentials of any kind? Yes ( )No ( )

If yes, do you intend to transfer them to the covering of the Potter’s House? Yes ( )No ( )

  1. What type(s) of vocational or work experience have you had?
  1. Please list the name, address and phone number of your current or most recent employer.
  1. Will your duties at your current position in any way conflict with classes? Yes ( ) No ( )

If yes, please explain.

MILITARY DATA

  1. Have you ever served in the U.S. Armed Forces? Yes ( )No ( )

If yes, list branch of service.

  1. Are you currently serving in the U.S. Armed Forces? Yes ( ) No ( )

If yes, please list branch of service.

Will your duties in any way conflict with classes? Yes ( )No ( )

If yes, please explain:

HEALTH DATA

  1. Are you in good health? Yes ( )No ( )

If not, please explain.

  1. Do you have any handicap or recurring condition which might interfere with your studies? Yes ( ) No ( )

If yes, please explain.

Applicants’ full signature:Date:

PHSOM STUDENT ENROLLMENT QUESTIONNAIRE

PLEASE DO NOT WRITE ON THIS QUESTIONNAIRE. TYPE ALL ANSWERS ON A SEPARATE SHEET OF PAPER AND ATTACH IT TO THIS QUESTIONNAIRE; ALL TO BE SUBMITTED WITH YOUR FULLY COMPLETED APPLICATION.

ALL QUESTIONS MUST BE ANSWERED AND PLEASE BE SPECIFIC IN YOUR ANSWERS.

  1. Give a brief statement of your salvation (conversion) experience.
  2. Tell briefly of your knowledge of your call to the Ministry.
  3. What is your chief reason/motive for wanting to enter the Ministry?
  4. Have you a settled conviction that it is God’s will that you enter the Ministry?
  5. What do you think about the Bible?
  6. Is the Bible true absolutely in every respect?
  7. How many Testaments are there?
  8. What is the relationship between the Old and the New Testaments?
  9. What is your belief about the Fall of Man?
  10. Are all human beings natural sinners, or do they have to learn it?
  11. Can any man improve his standing before God by good works?
  12. How are we saved?
  13. What is Grace?
  14. What is Predestination?
  15. Is Salvation free to all men?
  16. What is Justification?
  17. What is Sanctification?
  18. Who justified the sinner?
  19. Who atoned for the sinner?
  20. Explain Spiritual Gifts.

PHSOM Student Enrollment Application

© 2009 PHSOM, The Potter's House of Dallas, Inc.1