Step 1 of 5 20% Contact InformationName(Required) First Last Email(Required) Enter Email Confirm Email Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required) Christian Experience And BackgroundProvide the date and place of your conversion (salvation experience).Conversion Date(Required) MM slash DD slash YYYY Place Of Conversion(Required) Are you a member of The Potter’s House?(Required) Yes No Which campus ?(Required)DallasFt. WorthHow long you have been a member?(Required) If you are not a member of The Potter’s House, please answer the following questions:What is the name of your church?(Required) What is the name of your Pastor?(Required) What is the city of your church?(Required) What is the state of your church?(Required) Have you gained any Potter’s House (or other) non-accredited Bible teaching programs other than through the regularly scheduled Sunday & Wednesday services? If so, please list them. If no, please type N/A.(Required)Do you regularly attend Sunday service (at The Potter’s House or another ministry)?(Required) Yes No Do you regularly attend Mid-Week service (at The Potter’s House or another ministry)?(Required) Yes No Have you been baptized in water by immersion?(Required) Yes No What Christian work have you done?(Required)If not apply, please type NAWhat is the area of your passion in ministry?(Required) What types of activities do you enjoy?(Required)If not apply, please type NA Scholastic And Vocational DataIndicate the last year of high school that you successfully completed.(Required) If not apply, please type NAIndicate the following for post-secondary education.The highest level of college that you successfully completed.(Required) If not apply, please type NAThe Degrees/Certificates earned.(Required)If not apply, please type NAIf you are still attending college, please give the expected date of your graduation.(Required) If not apply, please type NAThe name, address, and phone number of the university/college attended.(Required) If you did not attend post-secondary school, please type N/A.Have you ever been dismissed, suspended, or asked to withdraw from any school?(Required) Yes No Please explain the reason and circumstances.(Required)If not apply, please type NAHave you ever been refused admission to any school?(Required) Yes No Please explain the reason and circumstances.(Required)Have you ever been warned about or placed on academic probation for low grades?(Required) Yes No If yes, please list the name, address, and phone number of the school.(Required)Have you previously taken a segment(s) of the PHSOM program?(Required) Yes No If yes, please list which one.(Required)Do you have ministerial credentials of any kind?(Required) Yes No If yes, please list them below.(Required)What type(s) of vocational or work experience have you had?(Required)If not apply, please type NA Employment DataAre you currently employed or an entrepreneur?(Required) Employed Entrepreneur Unemployed Will your duties at your current job in any way conflict with classes? If yes, please explain.(Required) Yes No If yes, please explain.(Required)Military DataHave you ever served in the U.S. Armed Forces?(Required) Yes No If yes, list the branch of service.(Required) Will your duties in any way conflict with classes?(Required) Yes No If yes, please explain.(Required)Health DataDo you have any handicap or recurring condition that might interfere with your studies?(Required) Yes No If yes, please explain.(Required)(Please note: This question is meant to give us the necessary information to properly accommodate and assist to ensure student success) PHSOM StudentWhat is your chief reason/motive for wanting to enter PHSOM?(Required) Do you have a settled conviction that it is God's will for you to enter the ministry?(Required) Yes No HiddenPHSOM DepartmentHiddenReceived By HiddenDate Received HiddenApproval Response HiddenResponse Date HiddenProcessing Information and Action Taken
