International Christian Counselors Alliance Certificate Program Application P.O. Box 1060, Rogers, Arkansas 72757-1060    501- 636-7497   800-494-7497  http://www.freedombiblecollege.org/icc.html Please type or print.  It is important to complete all information. To copy, select (highlight) this whole page by using "control A." After it is selected, use "control C" to copy.  Go to a blank page on your word processor and use "control V." PART I: Personal   1. Last Name ______________________First Name ______________________Middle ___________ 2. Address __________________________________________________ P.O. Box ________________ 3. City_________________________State________(Country)_______________Postal Code _______ 4. Home phone _________________ Office ________________ E-Mail_________________________ 5. Date of Birth (mm/dd/yy)  ______ /_____ /_____     SSN/SIN ______-______-______  Sex _____ 6. Church membership:_______________________________________________________________   PART II: Proctor (Subject to approval)    1. Proctor’s Name__________________________________________Phone_____________________ 2. Proctor’s Address __________________________________________ P.O. Box _______________ 3. City_________________________State________(Country)_______________Postal Code _______   PART III: Credentials   1. Credentials currently held:  Ministerial License ____    Ordination ____    Other _____      None _____ (Define if Other _____________________________________________________________________) 2. With what organization? ____________________________________________________________ 3. Do you plan to apply for credentials with Concepts of Freedom Ministries?  Yes____    No____  (For details on CFM credentials, please go to the web page <http://www.freedombiblecollege.org/ordination.html> or contact the office). 4. Do you plan to apply for membership with Freedom Christian Ministries Association?  Yes__  No___  5. If yes, will the application be for your counseling practice _____     church _____     both _____  (For details on FCMA membership, please go to the web page <http://www.freedombiblecollege.org/affiliate.html> or contact the office).   PART IV: Education   College Attended Location  Dates  Degree 1. . . . 2. . . . 3. . . . PART V: Financial  Standard Payment Breakdown First textbook (any difference from actual cost will be adjusted) Application fee (non refundable) First monthly payment (refundable only if your application is denied) Total $  29.00 $  25.00  $  60.00 $114.00 .. Alternate # 1 (use only if you are making other than the standard monthly payment) First textbook (any difference from actual cost will be adjusted) Application fee (non refundable) Payment (payments less than $60 must be approved by ICCA) Total $  29.00 $  25.00  $_____.__ $_____.__ Alternate # 2 I have chosen to pay my tuition of $325.00 in full and have enclosed  $_______ for textbooks. Check with the office to find the actual current cost of textbooks. Total   $______.__ .... (Applications will not be processed without the proper down payment) Part VI: ICCA Membership - (Check one) 1. ___ I understand that the first year membership is included in the tuition, but I wish to pay an additional $ ______ for _____ years ($50 per year). 2. ___ I would like a lifetime membership (contingent upon completing the ICCA Certificate Program) and I enclose $300.00 ($350 value ) (will be refunded upon your request if the program is not completed for any reason). 3. ____ I choose to pay membership fees each year as they become due.   Part VII: Signature This application must be completed and signed before it will be processed.  If you have questions about the application process, please call or email.  ______________________________________________                                 __________________ Signature of applicant                                                                                   Date signed Please help us serve you and future ICCA students better: 1.  How did you hear about the International Christian Counselors Alliance _______________________ 2.  Why did you choose ICCA?______________________________________ 3.  Suggestions or comments: ___________________________________________________________ ____________________________________________________________________________________     ICCA Use Only Student:     Yes                     No                     Yes with conditions  Proctor:      Yes                    No                     Yes with conditions         _____________________________________________________________________________________   CFM-ICCA Form 200                                                ©2000 Concepts of Freedom Ministries, Inc.