Registration Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I will be studying through: *

Internet

Distance Learning Center (DLC)

United School of Ministry

Received an institutional catalog. *

Yes

No

Was given the time and opportunity to review the institutional policies in the catalog. *

Yes

No

Has been informed of the length of the program for full-time and part-time students in academic terms and actual calendar time. *

Yes

No

Has been informed of the total tuition and other fees of the program. *

Yes

No

Has been informed of the estimated cost of books and any required equipment purchases such as a stenography machine, computer, specialized tools, art supplies, etc. *

Yes

No

Has been given a copy of the institutional refund policy. *

Yes

No

Has executed (signed) a Transfer of Credit Disclosure Statement in compliance with T.C.A. § 49-7-144 and understands the specific limitations should the institution have articulation agreements. *

Yes

No

Has been given the address and telephone number of Commission Staff (Tennessee Higher Education Commission, 404 James Robertson Parkway, Nashville, TN 37243-0830, (615) 741-5293) along with a statement that reads: “Any person claiming damage or loss as a result of any act or practice by the Church of God School of Ministry that is a violation of the Title 49, Chapter 7, Part 20 or Rule Chapter 1520-01-02 may file a complaint with the Tennessee Higher Education Commission, Division of Postsecondary State Authorization.”; and *

Yes

No

Has received the most recent withdrawal, completion, and placement data as calculated by the Commission in one of the ways described in Rule 1540-01-02-.13(1)(j). For the program titled Certificate in Ministerial Studies (CIMS), I have been informed that for the period of July 2018–June 2019, the withdrawal rate is .086%, the completion rate is .007%, and the in-field placement rate is .007%. Detailed statistical data for this program may be viewed by going to http://state.tn.us/thec and clicking on the “Authorized Institution’s Data” button. *

Yes

No

If applicable has received and understands the institution’s cash discount policy. *

Yes

No

Additionally, I affirm that the document clearly indicates that it is the Preenrollment Checklist, is paginated pursuant to Rule 1540-01-02-.13(1), and includes the full and correct name and address of the authorized location of the institution. I understand that if DSPA determines in the future that the Preenrollment Checklist is not compliant as described herein, my institution will be subject to adverse action pursuant to Rule 1540-01-02-.22. *

Yes

No

I, the student, have read and understand this document. *

Yes

No

Date *

MM

DD

YYYY