Form – CLICU

Full Name *

First

Middle

Last

Phone No. *

Email *

Country *

State *

Province/Local Government *

Street Name *

Date of Birth *

Gender

Marital Status *

Special Award in *

Please tick as appropriate

Level of Certification Applying for *

Please tick as appropriate

Entry Level *

Please tick as appropriate

Name of your Ministry/Church/Organization *

Area of Calling *

Please indicate current responsibility at your local assembly

Name of Referee *

First

Last

Reference Tel. No.

Your Expectation from the University

Signature

Write your full name in capital letters

Attestation *

Please tick

I promise to abide by the rules and regulations guiding my admission into this University. I promise to display a very high sense of responsibility. I agree that my admission can be terminated at any point in time if I am found wanting in speech and character.