ICCA Certificate Program Application

International Christian Counselors Alliance
Certificate Program Application
P.O. Box 1060, Rogers, Arkansas 72757-1060    501- 636-7497   800-494-7497 http://www.freedomministries.com/icc.html
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PART I: Personal

1. Last Name ______________________First Name ______________________Middle ___________
2. Address __________________________________________________ P.O. Box ________________
3. City_________________________State________(Country)_______________Postal Code _______
4. Home phone _________________ Office ________________ E-Mail_________________________
5. Date of Birth (mm/dd/yy) ______ /_____ /_____     SSN/SIN ______-______-______ Sex _____
6. Church membership:_______________________________________________________________

PART II: Proctor (Subject to approval)

1. Proctor’s Name__________________________________________Phone_____________________
2. Proctor’s Address __________________________________________ P.O. Box _______________
3. City_________________________State________(Country)_______________Postal Code _______

PART III: Credentials

1. Credentials currently held:
Ministerial License ____    Ordination ____    Other _____      None _____
(Define if Other _____________________________________________________________________)
2. With what organization? ____________________________________________________________
3. Do you plan to apply for credentials with Concepts of Freedom Ministries? Yes____    No____
(For details on CFM credentials, please go to the web page <http://www.freedomministries.com/ordination.html> or contact the office).
4. Do you plan to apply for membership with Freedom Christian Ministries Association? Yes__ No___
5. If yes, will the application be for your counseling practice _____     church _____     both _____
(For details on FCMA membership, please go to the web page <http://www.freedomministries.com/affiliate.html> or contact the office).

PART IV: Education

College Attended Location Dates Degree

1. . . .

2. . . .

3. . . .

PART V: Financial
Standard Payment Breakdown

First textbook (any difference from actual cost will be adjusted)
Application fee (non refundable)
First monthly payment (refundable only if your application is denied)
Total
$ 29.00
$ 25.00
$ 60.00
$114.00 ..

Alternate # 1 (use only if you are making other than the standard monthly payment)

First textbook (any difference from actual cost will be adjusted)
Application fee (non refundable)
Payment (payments less than $60 must be approved by ICCA)
Total
$ 29.00
$ 25.00
$_____.__
$_____.__

Alternate # 2

I have chosen to pay my tuition of $325.00 in full and have enclosed $_______ for textbooks. Check with the office to find the actual current cost of textbooks.
Total

$______.__ ....

(Applications will not be processed without the proper down payment)
Part VI: ICCA Membership - (Check one)

1. ___ I understand that the first year membership is included in the tuition, but I wish to pay an additional $ ______ for _____ years ($50 per year).
2. ___ I would like a lifetime membership (contingent upon completing the ICCA Certificate Program) and I enclose $300.00 ($350 value ) (will be refunded upon your request if the program is not completed for any reason).
3. ____ I choose to pay membership fees each year as they become due.

Part VII: Signature

This application must be completed and signed before it will be processed. If you have questions about the application process, please call or email.
______________________________________________                                 __________________
Signature of applicant                                                                                   Date signed

Please help us serve you and future ICCA students better:

1. How did you hear about the International Christian Counselors Alliance _______________________
2. Why did you choose ICCA?______________________________________
3. Suggestions or comments: ___________________________________________________________
____________________________________________________________________________________

ICCA Use Only

Student:     Yes                     No                     Yes with conditions
Proctor:      Yes                    No                     Yes with conditions         _____________________________________________________________________________________

CFM-ICCA Form 200                                                ©2000 Concepts of Freedom Ministries, Inc.