Contact Information

NAME:         First   Middle  Last 
 Preferred Name   Gender                                   

Citizenship      Birth date:               

PHONE:  Home   Work   Cell 

MAILING ADDRESS:  Address   City 
Province  Postal Code 

PERMANENT ADDRESS (if different):  Address   City 
Province  Postal Code 

Email  Address  


Marital and Family Status

Marital Status  If more than one applies, please explain below...

If you are separated or divorced please explain briefly...


If married: Name of Spouse   
Is your spouse in full agreement with your desire to attend PRBI? 

Do you have children?    If yes, how many? 
If you have children list their names and ages...




Family Information

Father's Name:
First   Last   Occupation 

Mother's Name:
First   Last   Occupation 

PHONE:  Home   Work   Cell 

Address   City   Province  
Postal Code 

If you have siblings list their names and ages...


OR

Guardian's Name:
First   Last   Occupation 

PHONE:  Home   Work   Cell 

Address   City   Province  
Postal Code 



Program Interest

If accepted, when do you plan to enroll?       Month      Year  
Which program are you interested in pursuing?  



References
Below list the three individuals you have chosen to give reference forms to.  Please note that there are specific categories of people that these forms should go to.  These individuals must not be family members, relatives, spouses, or boyfriends/girlfriends.  In each category, please choose the person who knows you best.

1. Name    Phone Number    
2. Name    Phone Number    
3. Name    Phone Number    

            * Download Character References Form (PDF*)


Education

Last high school grade completed:    High School graduation year: 
Have you received a Government-issued Diploma or GED? 
If home schooled, please list home schooled association (if applicable): 

Please list post secondary education that you have received:

1.  Name of Institute   City/Town          
.    Dates Attended      Level Awarded 

2.  Name of Institute   City/Town          
.    Dates Attended      Level Awarded 

3.  Name of Institute   City/Town          
.    Dates Attended      Level Awarded 

Please answer the following questions.
1. Has any post secondary institution ever refused your application? 
2. Has any post secondary institution ever placed you on suspension/probation? 
3. Has any post secondary institution ever dropped you from enrollment? 
4. Have you received any failing grades in any post secondary setting?  

If you answered yes to any of the above questions, please explain...




Other Personal Information 

1. Have you ever been convicted of a criminal offense, other than traffic violations? 
2. Have you  made frequent/repeated casual use of any of the following in the last five years?   
 Alcoholic Beverages    Tobacco     Non-prescription drugs 
3. Have you ever been involved in any occult practices? 

If you answered yes to any of the above questions, please explain...




Church Affiliation (home church) 

When did you acknowledged Jesus Christ as your personal Saviour? 

Name of Church  Denomination/Affiliation  
Pastor's name      Time you have been attending here? 
Phone #                 Address 
City     Province   Postal Code 

Are you a member?     Do your parents attend here?  


Ministry Involvement 

Describe the ministry involvement you have had in your church, Christian camps, missions, or service agencies:




Financial Information

How do you plan to finance your studies at PRBI?


Do you have sufficient funds on hand or available for your first year? 
Do you have any other financial obligations to which you are commited while attending PRBI?                                                   

If yes, please explain...

NOTE: While many student finance part of their education through government loans, we encourage you to not depend heavily on loan financing.  Information regarding Canada Students Loans and student aid is available form the PRBI Business office.


Medical Questionnaire References Only (PDF*)
Student Life Handbook (PDF*)

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