AGAPE UNIVERSITY ONLINE APPLICATION

How did you hear about Agape University
Last Name:
First Name:
Middle Initial:
Social Security Number:
Date of Birth:
Age:
Address:
City:
State:
Zip:
Phone #:
Cell #:
Email Address:
Country:
US Legal Status: US Citizen
Resident Alien
Non-Resident Alien
Health History
Please list disabilities
Please explain any accomodation you will need
Physical Problems Yes No
Hearing Problems Yes No
Speech Problems Yes No
Sight Problems Yes No
Emotional Problems Yes No
Other:
Yes NoIn the last 5 years, have you been enrolled in, required to enter into, or participated in any drug or alcohol recovery program or impaired practitioner program?
Yes NoIn the last 5 years, have you been treated for or had a recurrence of a diagnosed mental disorder or impairment?
Yes NoIn the last 5 years, have you been treated for or had a recurrence of a diagnosed physical impairment?
Yes NoIn the last 5 years, have you been treated for or had a recurrence of a diagnosed addictive disorder?

Education Level

Yes NoGraduated From High School
Yes NoReceived GED
Yes NoBachelor's Degree Obtained
Please list all schools attended beginning with High School:
School Name
Address
Course of Study
Years Attended
Degree/ Diploma Earned

Transportation

Yes NoDrivers License
Yes NoRestricted License
Yes NoStudents are required to travel to a variety of clinical sites. Do you have the ability to comply with this requirement.

Work History

Dates Employed
Company Name
Your Position

I am presently employed at:

Company Name & Address:
Position Held:
Supervisor:
Phone #:
Salary:

I have been laid off from:

Company Name & Address:
Are you a US Military Veteran? Yes No
If so, are you eligable for GI Bill®Benefits? Yes No
Are you planning to use your GI Bill®Benefits? Yes No

List any skills, certifications, licenses or special training you have:

Criminal Background:

Yes NoHave you ever been convicted of, or entered a plea of guilty, nolo contendre, or no contest to, a crime in any jurisdiction other than a minor traffic offense? You must include all misdemeanors and felonies, even if adjudication was withheld and even if you were a juvenile. Driving under the influence (DUI) or driving while impaired (DWI) is not a minor traffic offense for the purposes of this question.
Please Explain:

*You must have arrest and court records of final disposition for each offense listed

Program Applying For:
In the event that we are unable to contact you at the phone number you have given please provide two(2) additional contacts:
NameRelationshipPhone Number

In connection with my application to the Agape University, I understand that a consumer report, which may contain public records information is being requested

Electronic SignatureDate
(Typing your name here is equivilant to signing the application by hand)
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