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Antioch Baptist Bible College, Institute, Seminary & School of Christian Counseling
315 Grassdale Road
Cartersville, Ga. 30120

(Please fill in the blanks and circle appropriate answers)

Name, Last:                                              First:
Address 1:
Address 2:
City:                                          State:                           Zip:
Phone #: (* ):                     -                    -                    .
Other Phone #: (* ):                     -                    -                    .
(*)=(H)=Home, (W)=Work/Office, (Ch)=Church, (Cl)=Cell, (O)=Other

E-mail Address:
Number of Hours desired:
@ $75.00 per hr tuition: = $                 . 
(1 Sem. Hr. = 1 credit) (Amount Due):
Titles and/or Course #(s):
Additional info. may be added here:


Signature: ___________________

Thank You For The Information You've Provided.

Other Personal Informationtiontion
(Please fill in the blanks and circle appropriate answers.)

Date of Birth: Month:                    Day:                     Year:

First Class Date: Month:                    Day:                     Year:

Have you experienced "New Birth"? {Yes} {No} {Not Sure}

If so, When:                                       Where:

Have you been baptized? {Yes} {No} {Not Sure}.

If so, by what means?

Name of Church you attend:

Address: (If different, Please explain. Include helpful info):

Educational Background. (Schools, Degrees, Dates)

Please explain why you are considering Antioch College



Date Received_______ Date Cataloged _______

Date Filed _______ Transcript Received_____