Polis Application

First NameRequired

Middle NameRequired

Last NameRequired

Preferred NameRequired

SuffixRequired -- choose one -- CPA DDS Director Esquire I II III IV Jr. MD P.E. PhD RN Sr. U S Air Force U S Coast Guard U S Marine Corps U S Navy United States Army V

Primary Email AddressRequired

Social Security Number No Dashes (Required for IRS form 1098-T)Required

Date of BirthRequired

GenderRequired -- choose one -- Female Male Unknown

Are you Hispanic or Latino?Required -- choose one -- NO YES

What country represnts your primary citizenship?Required -- choose one -- UNITED STATES CANADA AFGHANISTAN ALBANIA ALGERIA ANDORRA ANGOLA ANTIGUA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA BOTSWANA BRAZIL BRUNEI BULGARIA BURKINA FASO BURMA BURUNDI CAMBODIA CAMEROON CAPE VERDE CENTRAL AFRICAN REPUBLIC CEYLON CHAD CHILE CHINA COLOMBIA COMOROS CONGO COSTA RICA CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR ENGLAND EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FIJI FINLAND FRANCE FRENCH ANTILLES FRENCH GUIANA GABON GAMBIA GEORGIA GERMANY GHANA GREECE GRENADA GUADELOUPE GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HOLY SEE HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN IRAQ IRELAND ISRAEL ITALY IVORY COAST JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA KUWAIT KYRGZSTAN LAOS LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW ZEALAND NICARAGUA NIGER NIGERIA NORTH KOREA NORTHERN IRELAND NORWAY OMAN PAKISTAN PALAU PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES POLAND PORTUGAL PRINCIPE QATAR REPUBLIC OF CHINA ROMANIA RUSSIA RWANDA SAN MARINO SAO TOME SAUDI ARABIA SCOTLAND SENEGAL SERBIA SEYCHELLES SIERRA LEON SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH KOREA SOUTH-WEST AFRICA SPAIN SRI LANKA ST. KITTS ST. LUCIA ST. NEVIS ST. VINCENT SUDAN SURINAME SWAZILAND SWEDEN SWITZERLAND SYRIA TAIWAN TAJIKSTAN TANZANIA THAILAND THE GRENADINES TOBAGO TOGO TONGA TRINIDAD TUNISIA TURKEY TURKMENISTAN TUVALU UAE UGANDA UKRAINE UNITED KINGDOM UPPER VOLTA URUGUAY UZBEKISTAN VANUATU VATICAN CITY VENEZUELA VIETNAM WALES WEST AFRICA WEST INDIES WESTERN SAMOA YEMEN ZAIRE ZAMBIA ZIMBABWE

Your Religious DenominationRequired -- choose one -- African Methodist Episcopal American Baptist Assembly of God Baptist Baptist Convention of Ontario Baptist General Conference Bible Fellowship Blank Allowed Brethern in Christ Church Brethren Church (Ohio) Christian & Missionary Allianc Christian Reformed Church Church of Christ Church of God (Anderson, IA) Church of God in Christ Church of the Brethren Church of the Nazarene Congregational Conservative Baptist Covenant Order of Evangelical Disciples of Christ Episcopal Church Evangelical Congregational Evangelical Free Church of Ame Evangelical Lutheran Church in Evangelical Presbyterian Churc Grace Brethren Church House of God Incorporated Independent Independent Baptist Independent Methodist Independent Presbyterian Interdenominational Korean Presbyterian Church in Lutheran Church (Missouri Syno Mennonite Methodist Moravian Nondenominational None North American Baptist Orthodox Presbyterian Church Other Other Baptist Other Independent Other Reformed Pentecostal Assemblies of Cana Pentecostal Other Plymouth Brethren Presbyterian Church of America Presbyterian Church of USA Presbyterian, Asc. Reformed Presbyterian, Other Progressive National Baptist Reformed Church in America Reformed Episcopal Roman Catholic Salvation Army Seventh Day Adventist Southern Baptist Convention United Brethren United Church of Christ United Methodist Unknown Wesleyan CHurch

Street 1Required

Street 2Required

Street 3Required

CityRequired

StateRequired -- choose one -- ALABAMA ALASKA AMERICAN EMBASSY AMERICAN SAMOA ARIZONA ARKANSAS ARMED FORCES THE PACIFIC CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

Zip CodeRequired Zip Code Extension

Primary Phone NumberRequired Primary Phone Number Area Code Primary Phone Number Exchange Primary Phone Number Number Primary Phone Number Extension  Ext: 

What is the highlest level of education you have completed?Required -- choose one -- College GED High School No Bachelor's Degree

Last school attended graduation monthRequired -- choose one -- January February March April May June July August September October November December

Last school attended graduation yearRequired -- choose one -- 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929

Last School AttendedRequired

College NameRequired

College NameRequired

Are you a U.S. armed services veteran?Required -- choose one -- No Yes

Please discuss any other information you feel should be considered when reviewing your applicationRequired

Are you the child or spouse of a MISSIO/BTS graduate?Required -- select one --No Yes

Have you ever been refused admittance or re-admittance by another seminary? If so, please explain.Required

Your Church NameRequired

Your Church Pastor's NameRequired

Church address 1Required

Church address 2Required

Church cityRequired

Church phoneRequired

Church stateRequired

Church zipRequired

Have you ever been convicted of a crime or pled guilty? If so, please list the date and place of the offense, the charge and the outcome.Required

Highest college degreeRequired -- select one --Bachelor's Associate's Master's Doctorate Other

If referred, please list name of person.Required

If you are the spouse or a child of a graduate, please list his or her name.Required

Maiden NameRequired

How did you hear about the Polis Institute at Missio?Required -- select one --Alumni Ambassador Board member Event Facebook Faculty Google Other Pastor Student Web search

Spouse NameRequired

What timeframe do you anticipate completing your program with approximately 120 hours of content?Required -- select one --3 months or less 3 to 6 months 6 months or more

Certificate program for which you are applying?Required -- select one --Certificate in Social Entrepreneurship

Have you ever started a business?Required -- select one --Yes No

If you started a business, is it currently operating?Required -- select one --Yes No

What is the main reason you are applying to the program?Required -- select one --You have an idea to start a business but don’t know what to do next You would like to belong to an entrepreneurial online support network/community You would like a business mentor You are ready to launch your business and would like to ensure you’ve completed the necessary ste Other

If you selected other, please describe.Required

If you are going to start a business, when do you plan on doing so?Required -- select one --In the next 6 months. In the next 6-12 months In 12 months or more

In what area would you like to make an impact with your new business?Required -- select one --Climate change Domestic violence Civil or human rights Youth development Health and wellness Education Other

If you selected other, please list here.Required