Membership Application Form

New Destiny University of Theology

10990 New Halls Ferry Rd Suite J #112
Ferguson, MO
314.393.0844

newdestinyuniversityoftheology.org
Application for Admissions
Applications will not be processed if the application fee of $45.00 has not been paid.
Which program do you wish to enroll?*
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Social Security Number*
Driver License Number
State
Click to edit

Option 1Option 2Option 3
Sex

MaleFemale
Marital Status

MarriedSingleDivorced
NName of Spouse
Primary E-mail*
Secondary E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Work Number

Area CodePhone Number
Home Number

Area CodePhone Number
Cellular Number

Area CodePhone Number
Background Information

(Information taken to better serve you as a student)
Present Occupation
How Long
Pastors Name
Pastors Phone Number

Area CodePhone Number
Name of your local church?
Local Church Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Are you clergy?

YesNo
Licensed?

YesNo
Ordained (Elder, Pastor, Evangelist)

YesNo
Consecrated (Overseer, Bishop, Apostle)

YesNo
What denomination do you classify yourself as being?
Citizenship
Ethnic Orgin

Caucasian (Non-Hispanic)Black (Non-Hispanic)Asian PAcific IslanderAmerican Indian/ AlaskanHispanicOther
Country of Birth
Are yo ua U.S. citizen? If No, please answer the following 5 questions

YesNo
Of what country are a citizen?
Are you a permanent U.S. resident?

YesNo
Alien registration #
Do you currently have a U.S. Visa?

YesNo
If Yes, what type of Visa?
Should be Empty:

Application for Admissions

Background Information