Mr. Mrs. Miss Title

First Name

Last Name

Middle Name

Birthday

Street Address

City State Zip

e-mail address

Phone Number (include area code)

USA Canada Other Citizenship (if other)


Race (optional)

Place of Birth

Single Married Widowed Divorced Marital Status

No Yes Have you ever been divorced or had a marriage annulled?
(If yes, please explain circumstances in the Comment field below.)

No Yes Do you have any children?
If yes, how many children?

ADMISSIONS INFORMATION

Spring 2009 Fall 2009 Spring 2010 Fall 2010 Other Entrance Date
First-year student Master's student Transfer Non-degreed student Audit student Applying as a...?
Yes No Will you be living on campus?
Yes No Will you have an automobile at school?

Probable Major

EDUCATIONAL BACKGROUND

High School Name

City State

Dates Attended

Date Graduated

N/A Yes No If you did not graduate from high school, do you have a GED?

No Yes Do you expect to transfer credits from another college?

If transferring credits, which college?

If transferring credits, city and state of college?

If transferring credits, dates attended?

Yes No If transferring credits, did you graduate?

N/A Yes No Are you eligible to return to the last college or university you attended?
(If no, please explain in the Comment field below.)
Yes No Have you taken the A.C.T.?
Yes No Are you being home-schooled?

FAMILY INFORMATION

Father's Name (Please indicate if deceased.)

Father's Occupation

Father's Permanent Street Address

City State Zip

Home Phone Work Phone

Mother's Name (Please indicate if deceased.)

Mother's Occupation

Yes No Mother's address same as above?

Mother's Permanent Street Address

City State Zip

Home Phone

Work Phone

PERSONAL INFORMATION

Name of your church (current membership)
Church Street Address

City State Zip

Church Phone

Name of Pastor

Pastor's Home Phone

No Yes Are you eligible to receive V.A. benefits?
Will you be applying for a scholarship at GSBC? If yes, please check the appropriate box:
N/A Missionary Pastor's Child

Check appropriate Box:
No Yes Have you any significant impairment?
No Yes Have you ever been treated for any nervous, mental, or emotional disorder, or been seen by a psychologist?
Yes No Have you ever used or sold illegal or dangerous drugs?
If so, when was the last time?
Yes No Have you ever used alcoholic beverages?
If so, when was the last time?
Yes No Have you ever used tobacco in any form?
If so, when was the last time?
Yes No Were you ever expelled, dropped, or suspended by any school or college?
Yes No Have you ever been arrested for any reason?
Yes No Have you ever been accused or convicted of any improper relation with a minor?
Yes No Is there anything else in your background about which we should know?

If any answer is yes, please give complete details below.

Comments/Additional Information

Upon submission of this application,
I certify that I have given full and complete information on this application for admission to Golden State Baptist College and that I have listed all schools and/or colleges I have attended. Furthermore, if admitted, I pledge to conduct myself in accordance with the standards outlined in the catalog and the student handbook.

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