H. ROSCOE UNIVERSITY REGISTRATION FORM

Name  ____________________________________________________________________________

                Last                                          First                                    Middle                      Maiden

Mailing Address  

__________________________________________________________________________________ 

              Number and Street                                      City/Town                               Zip

__________________________________________________________________________________

Day Telephone                                            Evening Telephone

FAX Number _____________________   e-mail ____________________________________________

Personal Data


Marital Status [   ] Single     [   ] Widowed     [   ] Divorced     [   ] Married


Educational Background

___________________________________________________________________________________

High School                                                     City/State                          Date of Graduation 

___________________________________________________________________________________

College or University                                       City/State                         Dates Attended   

Major                            Degree Earned     

___________________________________________________________________________________

College or University                                       City/State                         Dates Attended    

Major                            Degree Earned     

____________________________________________________________________________________

Church Affiliation  

 

Name of Church  ______________________________________________________________________

Pastor’s Name ________________________________________________________________________

Do you attend regularly?   [   ] Yes     [   ] No         Are you a member?  [   ] Yes    [   ] No

 

—I am enrolling in the following semester (s):  Fall [   ]    Spring [  ]      Summer [   ]


I am enrolling in Online Classes [   ]    Correspondence  [   ]       Face-to-Face  [   ]

Registration Fee $25.00:

Tuition Waiver:  Based on financial circumstances – must be approved by Dean of Institute      

I am paying by: _____check _____cash           Make checks payable to:  H. Roscoe University

 

Signature: __________________________________________   Date: ___________________________

 

By signing this application, I am indicating that I am in full agreement with the doctrinal statement of the             H. Roscoe University and, I agree to abide by the policies set forth in the catalog of the University.

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