The Therapon Institute - Register by Fax

APPLICATION FOR ADMISSION

Which school are you enrolling for?__________

City ______________________________________ Date: __________________

Name: _____________________________________________________________

Address: ___________________________________________________________

City: ______________________________________ State: ________________

Zip Code: ___________________ Date of Birth: _________________________

Home Telephone __________________________________________________

Work Phone: _____________________________________________________

Web Site Address ___________________________________________________

E-Mail Address _____________________________________________________

Recommended by _____________________________________, TI Consultant

Education: _____________ (Please follow up with copies of transcripts,
certificates, licenses, and/or certifications to complete your qualification
for enrollment. This information is vital for your certification file.

High School: __________________________________ City _______________

Colleges and/or Graduate Schools ____________________________________

1. ________________________________ Years: __________ Degree ______

2. _______________________________ Years: __________ Degree ______

3. ________________________________ Years: __________ Degree ______

4. ________________________________ Years: __________ Degree ______

Specialized Training: ________________________________________________
Please list all seminars, workshops, certifications, awards, and/or special training
you may have received.

1. _______________________________________________________________

2. _______________________________________________________________

3. _______________________________________________________________

4. _______________________________________________________________

Experience:

I am a/an ...... (Indicate with a check mark)

_____ Licensed Minister _____ Ordained Minister _____ LPC _____ LCDC

_____Certified Marriage & Family Counselor _____ LSW _____ CPE

_____ Christian Counselor _____ Pastor _____ Therapist _____Teacher

_____Treatment Assistant

_____ Addiction Counselor _____Chaplain ( _____ Criminal Justice
______ Medical _____ Industiral _____ Military ______
Other _______________________________________________)

How many years in the above? ________

Counseling Experience (hours) __________

Please list the number of years you have spent in the pastorate,
chaplaincy, counseling, teaching, etc. with a brief explanation.
Life experience becomes valuable credit.

Comments: ______________________________________________________

_________________________________________________________________

To use a Credit Card for your tuition,
please complete the following:

Name on the Card: _________________________________________________

Card Number: _____________________________________________________

Expiration Date: ___________ Amount to Charge $ 290.00

Authorization Signature: ____________________________________________

MAIL TO
Therapon Institute
Attn: David Rodriguez
5049 Ehret Road
Marrero, LA 70072

DRodrig704@aol.com