BEREAN STUDENT APPLICATION FORM

                                                                                                DR. PHIL GOBLE

                                                                                                C/O ARTISTS FOR ISRAEL INSTITUTE

                                                                                                P.O. BOX 2056

                                                                                                NEW YORK NY 10163

                                                                                                TEL: 646 460 5971

NAME______________________________________________        DATE______________________________________

ADDRESS___________________________________________        HOME PHONE______________________________

CITY/STATE/ZIP_____________________________________        WORK PHONE______________________________

SOCIAL SECURITY NUMBER _________________________        CELL PHONE_______________________________

(REQUIRED FOR REGISTRATION)

NOTE: STUDENTS MUST COMPLETE STUDY CENTER REGISTRATION FORM

HOME CONGREGATION:_________________________________________________________

EMAIL ADDRESS:_______________________________________________________________

BEREAN STUDENT NUMBER (RETURNING STUDENT)_______________________________

7:30-8:30 P.M.  INTRODUCTION TO HOMILETICS (HOW TO PREACH)                            $95.00

                          INSTRUCTOR: REV. PHIL GOBLE

                                            COST FOR COURSE  $95.00

                                            REGISTRATION FEE   10.00

                                    NEW STUDENT FEE            25.00

                                                        TOTAL

                                            LESS CASH DEPOSIT________

                                            LESS CHECK DEPOSIT______

                                        BALANCE DUE_______________

(MAKE CHECKS PAYABLE TO CONGREGATION BETH SHALOM)