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Student Missionaries 04-05

Pre-Application

Student ID# Today's Date

Last Name First Name Middle Name

Preferred Country of Service

Local/Dorm Address

Phone/Ext Work Phone Email Address

Gender Male
Female Major

Birthdate(MM/DD/YYYY)
Birthplace(City, State, Country)

Class Standing This Year Freshman
Sophomore
Junior
Senior

Are You Baptized? Yes
No
Date of Baptism(MM/DD/YYYY)

Membership at Church

Do you have a passport? Yes
No
Passport Country

Do you have a student loan that will need to be deferred? Yes
No
Don't Know

Do you plan to return to Southwestern after your service as a missionary? Yes
No

Do you require any medication for your health? Yes
No
If yes, please explain:

List three choices of places to serve, in order of preference. 1.
2.
3.

Address #1
Father's/Guardian's Name

Address

Email

Home Phone Work Phone Fax

Address #2
Mother's/Guardian's Name

Address

Email

Home Phone Work Phone Fax

Which address above is your permanent home address? Address #1
Address #2

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