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 $85.00:

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

 "H. Roscoe University is a religious educational institution operating in the State of Maryland pursuant to an exemption granted by the Maryland Higher Education Commission, without a certificate of approval from the Commission, as specified in the Code of Maryland Regulations 13B.02.04."

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.

Signature: __________________________________________   Date: ___________________________


Make a free website with Yola