ACADEMY OF INTEGRATED CHRISTIAN STUDIES Shekina Hill, MZU Road, Tanhril, Post Box No. 80, Aizawl- Mizoram, 796 001 (India) APPLICATION FORM FOR ADMISSION Affix Passport Size Self Attested Recent Photograph Last Date of Submission: th 30 March 2015 Entrance Exam: nd 22 April, 2015 BTE Interview: rd 23 April, 2015 Course: B.D/M. Div./ Dip.MS/Dip.CM Tick against the course for which admission is sought. 1. Name : ________________________________________ 2. Parent’s Name: i) Father’s Name :_________________________________________ ii) Mother’s Name :_________________________________________ Full Postal Address :_________________________________________ _________________________________________ Telephone No. 3. Name of Guardian Full Postal Address :_________________________________________ :_________________________________________ :_________________________________________ _________________________________________ Telephone No. :_________________________________________ 5. Date of Birth :_________________________________________ 6. Married or Unmarried :_________________________________________ 7. Mother Tongue :_________________________________________ 1 8. Academic Qualifications: Examination Passed Name of University/ Board/School College/School Attended Year of Passing Reg.No. Class/ Grade 9. What are your past and present responsibilities/employment? (a) In the Church:___________________________________________ (b) In other Sectors: ________________________________________ 10. Church (Denomination) of which you are a member: _________________________________________________________ 11. Name and Address of your Pastor/Presbyter: (Letter of your Pastor/Presbyter stating your status and activity in the Church should be enclosed) ______________________________________________________________________ 12. Are you ordained? Yes/ No (for BD & M.Div. candidates) (If ordained, date of Ordination) ____________________________________________________ 13. Do you want to be ordained? Yes/No. _________________________________________________________ 14. Are you a sponsored Candidate of your Church/Institution/Organization? (If so, give the name of the Church/Institution/Organization responsible for the sponsorship. Enclose a letter from the authority sponsoring your candidature). _________________________________________________________ 15. Are you an Independent Candidate? (If so, give the name of the person responsible for your support while studying. Enclose a letter from the person who will be responsible for your financial support ) ________________________________________________________ 16. Complete the following: (for independent candidates) i) Occupation of your parents or guardian responsible for your sponsorship. ____________________________________________________ 2 ii) Annual income of your parents or guardian who is responsible for your sponsorship. Rs. ____________(Rupees___________________________) 17. Have you ever smoked? (If yes, when did you give up?) Yes/No _________________________________________________________ 18. Have you ever drunk liquor? (If yes, when did you give up?) Yes/No _________________________________________________________ 19. Have you ever used Drugs? Yes/No If yes, which type of drugs? How long did you use them for? When did you stop using them? _________________________________________________________ 20. What motivates you to do Theology/Music/Missionary Training? _________________________________________________________ 21. Why did you choose the Academy of Integrated Christian Studies? _________________________________________________________ _________________________________________________________ _________________________________________________________ 22. What is your aim after you complete your course? _________________________________________________________ 23. If you are admitted, do you promise to live according to the discipline laid down in the rules and regulations? Yes/No 24. Promise of Fidelity; If admitted to AICS, I ____________________________________(name) promise the following: i) That I will abide by the Rules and Regulations of the Academy of Integrated Christian Studies. ii) That If I am found smoking or using tobacco in any form, drinking alcohol or using drugs the Authorities may ask me to leave AICS. Date:_____________ Signature:________________________ 3 INFORMATION 1. Attach the following documents along with the Application Form: i) Attested copies of academic documents- Marksheet and Certificate from HSLC & Above ii) Self attested recent passport size photograph. iii) A letter from your church/organization which testifies to your membership and your involvement in the church/ministry. iv) Birth Certificate or other acceptable evidence of date of birth. v) Statement of experience in Church Music (for Dip. CM candidates) Vi) Any additional information and references that may be considered desirable in support of your application. Vii) Original academic documents should be submitted by the time of admission. Note/s: BD= M.Div. = Dip. MS= Dip. CM= 4 Bachelor of Divinity Master of Divinity Diploma in Mission Studies Diploma in Church Music ACADEMY OF INTEGRATED CHRISTIAN STUDIES Shekina Hill, Aizawl Health History to be completed by the candidate before Medical Examination Candidate’s Name: _________________________________________ FAMILY HISTORY: ANY ILLNESS IF DEATH (deceased) CAUSE OF DEATH 1. Father: 2. Mother: 3. Sister/Brother: 4. Wife/Husband: MEDICAL HISTORY (Indicate dates of any of the following conditions you have had). 1. Typhoid 2. Malaria 3. Jaundice 4. Dysentery 5. Diphtheria 6. Chicken Pox 7. Mumps 8. Filariasis 9. Joint Pains 10. Rheumatic Fever 11. Recent loss/gain in weight 12. Pleurisy 13. T.B. 14. Tonsilitis 15. Easy Fatigue 16. Piles 17. Shortness of Breath 18. Heart Trouble 19. High B.P. 20. Asthma 21. Diabetes 22. Appendicitis 23. Stomach trouble 24. Skin Disease 25. Eye Problem 26. Discharging Ears 27. Backache 28. Deafness 29. Nervous Breakdown 30. Depression 31. Sleeplessness 32. Lack of Confidence 33. Fainting Spells 34. Dizziness 35. Fits 36. Inability to concentrate FOR WOMEN ONLY: 1. Menstrual Irregularities 2. Pregnancies 3. Present or Past Treatment for Female Disorder Any operation or injuries: Any deformities: Medication being taken and date and dosage: FOR ALL: I certify that I have answered the above questions fully and honestly. So far as my knowledge is concerned there are no other significant health facts known to me. Date:_____________ Signature: _________________________ 5 (TO BE DONE BY THE PHYSICIAN ONLY) Eye Visual Acuity Distant Vision Near Vision Pupils Eyelids Glands Hearing Cervical Nose &Throat Skin Rash Axillary Inguinal CERCULATORY SYSTEM B.P: Peripheral Pulses Varicose Veins Pulse Posture Spine Hands & Feet Gait ORTHOPAEDIC: RESPIRATORY INSPECTION: Abdomen Lungs Liver Spleen Teeth & gums Hernia NERVOUS SYSTEM: Higher Function Reflexes Speech other Abnormality Motor EMOTIONAL STABILITY: Evidence of Psychiatric disorders LABORATORY EXAMINATION: Stool Urine H.B. % WMC …..T…..P….L…..M…..E…..B….. Blood Group:__________________ Chest X-Ray Summary of current findings: FITNESS FOR STUDY: I consider that the candidate is physically fit to undertake theological training/any professional course of study. Date: _____________ Physician’s Signature: ___________________ Physician’s Name: _____________________ Designation: _____________________ Address: _____________________ _____________________ 6