ACADEMY OF INTEGRATED CHRISTIAN STUDIES Road, Tanhril, Post Box No. 80,

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
:_________________________________________
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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.
____________________________________________________
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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:________________________
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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=
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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: _________________________
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(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:
_____________________
_____________________
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