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Sep 3rd, 2015
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  1. <?php
  2.  
  3. if(isset($_POST['submit'])){
  4.     $firstname = $_REQUEST['firstname'];
  5.     $middlename = $_REQUEST['middlename'];
  6.     $lastname = $_REQUEST['lastname'];
  7.     $title = $_REQUEST['title'];
  8.     $birth_date = $_REQUEST['birth_date'];
  9.     $gender = $_REQUEST['gender'];
  10.     $marital_status = $_REQUEST['marital_status'];
  11.     $boys = $_REQUEST['boys'];
  12.     $address = $_REQUEST['address'];
  13.     $city = $_REQUEST['city'];
  14.     $state = $_REQUEST['state'];
  15.     $zipcode = $_REQUEST['zipcode'];
  16.     $attent_services = $_REQUEST['attent_services'];
  17.     $offen_services = $_REQUEST['offen_services'];
  18.     $bible_study = $_REQUEST['bible_study'];
  19.     $offen_bible = $_REQUEST['offen_bible'];
  20.     $old_testament  = $_REQUEST['old_testament'];
  21.     $new_testament = $_REQUEST['new_testament'];
  22.     $verse  = $_REQUEST['verse'];
  23.     $fvcharacter = $_REQUEST['fvcharacter'];
  24.     $heigh_school = $_REQUEST['heigh_school'];
  25.     $heigh_school_state = $_REQUEST['heigh_school_state'];
  26.     $graduate = $_REQUEST['graduate'];
  27.     $graduate_year = $_REQUEST['graduate_year'];
  28.     $ged = $_REQUEST['ged'];
  29.     $ged_year = $_REQUEST['ged_year'];
  30.     $learn_aboutus = $_REQUEST['learn_aboutus'];
  31.     $friend_name1 = $_REQUEST['friend_name1'];
  32.     $friend_related1 = $_REQUEST['friend_related1'];
  33.     $friend_address1 = $_REQUEST['friend_address1'];
  34.     $friend_city1 = $_REQUEST['friend_city1'];
  35.     $friend_state1 = $_REQUEST['friend_state1'];
  36.     $friend_zip1 = $_REQUEST['friend_zip1'];
  37.     $friend_email1 = $_REQUEST['friend_email1'];
  38.     $friend_telephone1 = $_REQUEST['friend_telephone1'];
  39.     $friend_name2 = $_REQUEST['friend_name2'];
  40.     $friend_related2 = $_REQUEST['friend_related2'];
  41.     $friend_address2 = $_REQUEST['friend_address2'];
  42.     $friend_city2 = $_REQUEST['friend_city2'];
  43.     $friend_state2 = $_REQUEST['friend_state2'];
  44.     $friend_zip2 = $_REQUEST['friend_zip2'];
  45.     $friend_email2 = $_REQUEST['friend_email2'];
  46.     $friend_telephone2 = $_REQUEST['friend_telephone2'];
  47.     $list_occupational = $_REQUEST['list_occupational'];
  48.     $list_church = $_REQUEST['list_church'];
  49.     $goals = $_REQUEST['goals'];
  50.     $wish_perticipate = $_REQUEST['wish_perticipate'];
  51.     $college_name1 = $_REQUEST['college_name1'];
  52.     $college_state1 = $_REQUEST['college_state1'];
  53.     $degree1 = $_REQUEST['degree1'];
  54.     $degreecompletion1 = $_REQUEST['degreecompletion1'];
  55.     $college_name2 = $_REQUEST['college_name2'];
  56.     $college_state2 = $_REQUEST['college_state2'];
  57.     $degree2 = $_REQUEST['degree2'];
  58.     $degreecompletion2 = $_REQUEST['degreecompletion2'];
  59.     $college_name3 = $_REQUEST['college_name3'];
  60.     $college_state3 = $_REQUEST['college_state3'];
  61.     $degree3 = $_REQUEST['degree3'];
  62.     $degreecompletion3 = $_REQUEST['degreecompletion3'];
  63.     $ministry_year = $_REQUEST['ministry_year'];
  64.     $military_service  = $_REQUEST['military_service'];
  65.     $military_service_branch  = $_REQUEST['military_service_branch'];
  66.     $relationships_description  = $_REQUEST['relationships_description'];
  67.     $employed_place  = $_REQUEST['employed_place'];
  68.     $salary  = $_REQUEST['salary'];
  69.     $earn_lastyear  = $_REQUEST['earn_lastyear'];
  70.     $paying_for_education  = $_REQUEST['paying_for_education'];
  71.     $assist_covering_costs  = $_REQUEST['assist_covering_costs'];
  72.     $interested_degree  = $_REQUEST['interested_degree'];
  73.     $ordination_program  = $_REQUEST['ordination_program'];
  74.     $signature  = $_REQUEST['signature'];
  75.     $print_name  = $_REQUEST['print_name'];
  76.     $current_date  = date("Y-m-d");
  77.        
  78.  
  79.  
  80.  
  81.  
  82. $mailbody = "<html><body bgcolor='#8d8e90'><table width='100%' border='0' cellspacing='0' cellpadding='0' bgcolor='#8d8e90'>
  83.  <tr>
  84.    <td><table width='600' border='0' cellspacing='0' cellpadding='0' bgcolor='#FFFFFF' align='center'>
  85.        <tr>
  86.          <td><table width='100%' border='0' cellspacing='0' cellpadding='0'>
  87.              <tr>
  88.               <td width='100%' style='text-align:center;'><a href= 'http://iccscampus.org' target='_blank'><img src='http://iccscampus.org/wp-content/themes/iccscampus/images/logo.png' alt=''/></a></td>
  89.                <td width='393'><table width='100%' border='0' cellspacing='0' cellpadding='0'>
  90.                    <tr>
  91.                      <td height='46' align='right' valign='middle'><table width='100%' border='0' cellspacing='0' cellpadding='0'>
  92.                          
  93.                        </table></td>
  94.                    </tr>
  95.                  
  96.                  </table></td>
  97.              </tr>
  98.            </table></td>
  99.        </tr>
  100.      
  101.        <tr>
  102.          <td align='center' valign='middle'><table width='100%' border='0' cellspacing='0' cellpadding='0'>
  103.            
  104.            </table></td>
  105.        </tr>
  106.        <tr>
  107.          <td>&nbsp;</td>
  108.        </tr>
  109.        <tr>
  110.          <td><table width='100%' border='0' cellspacing='0' cellpadding='0'>
  111.              <tr>
  112.                <td width='5%'>&nbsp;</td>
  113.                <td width='90%' valign='middle'><font style='font-family: Verdana, Geneva, sans-serif; color:#68696a; font-size:12px; line-height:20px;'>
  114. First Name - ".$firstname. "<br/> Middle Name - ".$middlename. "<br/> Last Name - ".$lastname. "<br/> Title - ".$title. "<br/>
  115. Date Of Birth - ".$birth_date. "<br/> Gender - ".$gender. "<br/>
  116. Marital Status - ".$marital_status. "<br/>
  117. How Many Children? - ".$boys. ", <br/>
  118. Address - ".$address. "<br/> City - ".$city. "<br/> State - ".$state. ",<br/>
  119. Zipcode - ".$zipcode. "<br/> Do you attend services?: - ".$attent_services. "<br/> How Often? - ".$offen_services. "<br/>
  120. Do you attend Bible Study? - ".$bible_study. "<br/>
  121. How Often? - ".$offen_bible. "<br/>
  122. What is your favorite Old Testament book in the Bible? - ".$old_testament. "<br/>
  123. What is your favorite New Testament book in the Bible? - ".$new_testament. "<br/>
  124. What is your favorite Verse in the Bible? - ".$verse. "<br/>
  125. Who is your favorite character in the Bible and why? - ".$fvcharacter. "<br/>
  126. Name of High School - ".$heigh_school. "<br/>
  127. Heigh School State - ".$heigh_school_state. "<br/>
  128. Did you graduate? - ".$graduate. "<br/>
  129. If Yes, What Year - ".$graduate_year. "<br/>
  130. If No, do you have your GED - ".$ged. "<br/>
  131. If Yes, What Year - ".$ged_year. "<br/>
  132. How did you learn about us? - ".$learn_aboutus. "<br/>
  133. To help students pay for their education we have created the prospective sponsor program as part of this program we will draft a letter for you to be sent to individuals who you believe may be able to help pay all or part of your educational expenses. Please provide the first and last name of the up to three individuals who you believe may be able to assist you.<br/>
  134. List any friends, family, or possible supporter of your educational goals in the space provided below.<br/>
  135.  
  136. Name - ".$friend_name1. "<br/>
  137. How are they related to you - ".$friend_related1. "<br/>
  138. Address - ".$friend_address1. "<br/>
  139. City - ".$friend_city1. "<br/>
  140. State - ".$friend_state1. "<br/>
  141. Zip - ".$friend_zip1. "<br/>
  142. Email Address - ".$friend_email2. "<br/>
  143. Telephone No - ".$friend_telephone2. "<br/>
  144. Name - ".$friend_name2. "<br/>
  145. How are they related to you - ".$friend_related2. "<br/>
  146. Address - ".$friend_address2. ",<br/>
  147. City - ".$friend_city2. "<br/>
  148. State - ".$friend_state2. "<br/>
  149. Zip - ".$friend_zip2. "<br/>
  150. Email Address - ".$friend_email2. "<br/>
  151. Telephone No - ".$friend_telephone2. "<br/>
  152. Please complete the following information to the best of your knowledge:<br/>
  153. A)  List Occupational / Employment History Related and Special Training and Ministry Experience - ".$list_occupational. "<br/>
  154. B)  List Church Involvement and Extracurricular Activities (Boy Scouts, Vacation Bible School, Sports, etc.) - ".$list_church. "<br/>
  155. C)  What Are Your Educational And Professional Goals? - ".$goals. "<br/>
  156. D)  Why Do You Wish To Participate In This Program? - ".$wish_perticipate. "<br/><br/>
  157. Please write the degree(s) you have obtained below.
  158. <table width='100%' border='0' cellspacing='0' cellpadding='0'>
  159. <tr style='background:#555555; color:#fff; text-align:left;'>
  160. <th width='35%'>Name of School/College</th>
  161. <th width='15%'>State</th>
  162. <th width='15%'>Degree</th>
  163. <th width='35%'>Date of Completion</th>
  164. </tr>
  165. <tr>
  166. <td width='35%'>".$college_name1. "</td>
  167. <td width='15%'>".$college_state1. "</td>
  168. <td width='15%'>".$degree1. "</td>
  169. <td width='35%'>".$degreecompletion1. "</td>
  170. </tr>
  171. <tr>
  172. <td width='35%'>".$college_name2. "</td>
  173. <td width='15%'>".$college_state2. "</td>
  174. <td width='15%'>".$degree2. "</td>
  175. <td width='35%'>".$degreecompletion2. "</td>
  176. </tr>
  177. <tr>
  178. <td width='35%'>".$college_name3. "</td>
  179. <td width='15%'>".$college_state3. "</td>
  180. <td width='15%'>".$degree3. "</td>
  181. <td width='35%'>".$degreecompletion3. "</td>
  182. </tr>
  183.            </table>
  184. Years in Ministry - ".$ministry_year. "<br/>
  185. Military Service - ".$military_service. "<br/>
  186. If Yes, what branch(s)? - ".$military_service_branch. ",<br/>
  187. Please give a brief statement about your relationships with your family Mother, Father, Siblings, Children, etc. - ".$relationships_description. "<br/>
  188. Where are you employed l? - ".$employed_place. "<br/>
  189. Monthly Salary? - ".$salary. "<br/>
  190. How much did you earn last year? - ".$earn_lastyear. "<br/>
  191. How do you plan on paying for your education? - ".$paying_for_education. "<br/>
  192. Do you have friends and possible supporters of your educational goals that would assist in covering costs of material, books, and tuition including the cost of shipping the course materials to you? (Please explain)".$assist_covering_costs. ",<br/>
  193. What degree Program are you currently interested in? - ".$interested_degree. "<br/>
  194. Are you interested in the Ordination Program? - ".$ordination_program. ",<br/>
  195. Signature - ".$signature. "<br/>
  196. Print Name - ".$print_name. "<br/>
  197. Date - ".$current_date. "<br/>
  198. </td>
  199. </tr>
  200.  
  201. </table></td>
  202.        </tr>
  203.        <tr>
  204.          <td>&nbsp;</td>
  205.        </tr>
  206.        <tr>
  207.          <td>&nbsp;</td>
  208.        </tr>
  209.        
  210.        <tr>
  211.          <td>&nbsp;</td>
  212.        </tr>
  213.      </table></td>
  214.  </tr>
  215. </table></body></html>";
  216.  
  217. $user_email = 'sbbrhs@gmail.com';
  218. $suject = "SUBJECT";
  219. $headers =  'From: me@gmail.com' . "\r\n" .
  220.                 'Reply-To: me@gmail.com' . "\r\n" .
  221.                 'X-Mailer: PHP/' . phpversion() . "\r\n" .
  222.                 'Content-Type: text/html; charset=ISO-8859-1'."\r\n".
  223.                 'MIME-Version: 1.0'."\r\n\r\n";
  224.  
  225.     mail($user_email, $suject, $mailbody , $headers);
  226.                  
  227.  
  228.     }
  229.  
  230.  
  231. //get_header();
  232. ?>
  233.  
  234.  
  235.  
  236.  
  237.  
  238.  
  239. <div class="commonBlock pageContent">
  240.                     <h3><?php //the_title() ?></h3>
  241.                    
  242.                    
  243.                    
  244.                    
  245.                    <div class="common iccsformsub">
  246.                    
  247. <form name="form1" id="form1" action="" method="post">
  248. <p class="successMessage"><b>Successfully Data Submitted</b></p>
  249. <div class="commonBlock icsFormBody formPersonal">
  250. <p>
  251.     <label>First Name:  </label>
  252.     <span><input type="text" name="firstname" value="" size="40" class="common fcField" placeholder="First Name" /></span>
  253.  </p>
  254.     <p>
  255.     <label>Middle Name:  </label>
  256.     <span><input type="text" name="middlename" value="" size="40" class="common fcField" placeholder="Middle Name" /></span>
  257.  </p>
  258.   <p>
  259.     <label>Last Name:  </label>
  260.     <span><input type="text" name="lastname" value="" size="40" class="common fcField" placeholder="Last Name" /></span>
  261.  </p>
  262.   <p>
  263.     <label>Your Title </label>
  264.     <span><input type="text" name="title" value="" size="40" class="common fcField" placeholder="Title" /></span>
  265.  </p>
  266.  <p>
  267.     <label>Date of Birth:  </label>
  268.     <span><input type="text" name="birth_date" value="" size="40" class="common fcField" placeholder="Date of Birth" /></span>
  269.  </p>
  270.  <p>
  271.     <label>Gender</label>
  272.     <span><em class="attend_service"><input type="radio" value="Male" name="gender">
  273.     Male
  274.     <input type="radio" value="Female" name="gender">
  275.     Female</em></span>
  276.     </p>
  277.  <p>
  278.     <label>Marital Status</label>
  279.     <span><em class="attend_service"><input type="radio" value="Married" name="marital_status">
  280. Married
  281.    <input type="radio" value="Single" name="marital_status">
  282.     Single</em></span>
  283.     </p>
  284.   <p>
  285.     <label>How Many Children? </label>
  286.     <span><input type="text" name="boys" value="" size="40" class="common fcField" placeholder=" How Many Children?" /></span>
  287.  </p>
  288. </div>
  289. <div class="commonBlock icsFormBody formPersonal">
  290.     <h3>ADDRESS INFORMATION</h3>
  291. <p>
  292.     <label>Address:  </label>
  293.     <span><input type="text" name="address" value="" size="40" class="common fcField" placeholder="Address" /></span>
  294.  </p>
  295.  <p>
  296.     <label>City:  </label>
  297.     <span><input type="text" name="city" value="" size="40" class="common fcField" placeholder="City" /></span>
  298.  </p>
  299.  <p>
  300.     <label> Your State:  </label>
  301.     <span><input type="text" name="state" value="" size="40" class="common fcField" placeholder="State" /></span>
  302.  </p>
  303.  <p>
  304.     <label>Zipcode:  </label>
  305.     <span><input type="text" name="zipcode" value="" size="40" class="common fcField" placeholder="Zip" /></span>
  306.  </p>
  307.  </div>
  308.  <div class="commonBlock icsFormBody formPersonal">
  309.     <h3>RELIGIOUS INFORMATION</h3>
  310.  
  311. <p>
  312.     <label>Do you attend services?</label>
  313.     <span><em class="attend_service"><input type="radio" value="Yes" name="attent_services">
  314.     Yes
  315.     <input type="radio" value="No" name="attent_services">
  316.     No</em><br/><em class="often_service">How Often?</em><span><input type="text"  name="offen_services" value="" size="40" class="common fcField" placeholder="" /></em></span>
  317.     </p>
  318.    
  319.     <p>
  320.     <label>Do you attend Bible Study? </label>
  321.     <span><em class="attend_service"><input type="radio" value="Yes" name="bible_study">
  322.     Yes
  323.     <input type="radio" value="No" name="bible_study">
  324.     No</em><br/><em class="often_service">How Often?</em><span><input type="text"  name="offen_bible" value="" size="40" class="common fcField" placeholder="" /></em></span>
  325.     </p>
  326.  
  327. <p>
  328.     <label class="favourite_testment">What is your favorite Old Testament book in the Bible?  </label>
  329.     <span class="out_look"><input type="text" name="old_testament" value="" size="20" class="common fcField" placeholder="" /></span>
  330.  </p>
  331.  <p>
  332.     <label class="favourite_testment">What is your favorite New Testament book in the Bible?  </label>
  333.     <span class="out_look"><input type="text" name="new_testament" value="" size="20" class="common fcField" placeholder="" /></span>
  334.  </p>
  335.  <p>
  336.     <label class="favourite_testment">What is your favorite Verse in the Bible?  </label>
  337.     <span class="out_look"><input type="text" name="verse" value="" size="20" class="common fcField" placeholder="" /></span>
  338.  </p>
  339.  <p>
  340.     <label class="favourite_testment">Who is your favorite character in the Bible and why?  </label>
  341.     <span class="out_look"><input type="text" name="fvcharacter" value="" size="20" class="common fcField" /></span>
  342.  </p>
  343.  
  344.  
  345.     </div>
  346. <div class="commonBlock icsFormBody formPersonal">
  347.     <h3>EDUCATIONAL INFORMATION</h3>
  348.     <p>
  349.     <label>Name of High School:  </label>
  350.     <span><input type="text" name="heigh_school" value="" size="40" class="common fcField" /></span>
  351.  </p>
  352.  <p>
  353.     <label>School State:  </label>
  354.     <span><input type="text" name="heigh_school_state" value="" size="40" class="common fcField" /></span>
  355.  </p>
  356.  <p>
  357.     <label>Did you graduate?</label>
  358.     <span><em class="attend_service"><input type="radio" value="Yes" name="graduate">
  359.     Yes
  360.     <input type="radio" value="No" name="graduate">
  361.     No</em></span>
  362.     </p>
  363.     <p>
  364.     <label>If Yes, What Year:  </label>
  365.     <span><input type="text" name="graduate_year" value="" size="40" class="common fcField" /></span>
  366.  </p>
  367. </div>
  368. <div class="commonBlock icsFormBody formPersonal">
  369.     <p>
  370.     <label>If No, do you have your GED:</label>
  371.     <span><em class="attend_service"><input type="radio" value="Yes" name="ged">
  372.     Yes
  373.     <input type="radio" value="No" name="ged">
  374.     No</em></span>
  375.     </p>
  376.      <p>
  377.     <label>If Yes, What Year:  </label>
  378.     <span><input type="text" name="ged_year" value="" size="40" class="common fcField"/></span>
  379.  </p>
  380.   <p>
  381.     <label>How did you learn about us?  </label>
  382.     <span><input type="text" name="learn_aboutus" value="" size="40" class="common fcField"/></span>
  383.  </p>
  384. </div>
  385. <div class="commonBlock icsFormBody formPersonal">
  386. <p>
  387. To help students pay for their education we have created the prospective sponsor program as part of this program we will draft a letter for you to be sent to individuals who you believe may be able to help pay all or part of your educational expenses. Please provide the first and last name of the up to three individuals who you believe may be able to assist you.<br/>
  388. List any friends, family, or possible supporter of your educational goals in the space provided below.
  389. </p>
  390. <p>
  391.     <label>Name:  </label>
  392.     <span><input type="text" name="friend_name1" value="" size="40" class="common fcField" /></span>
  393.  </p>
  394.  <p>
  395.     <label>How are they related to you:  </label>
  396.     <span><input type="text" name="friend_related1" value="" size="40" class="common fcField" /></span>
  397.  </p>
  398.  <p>
  399.     <label>Address:  </label>
  400.     <span><input type="text" name="friend_address1" value="" size="40" class="common fcField" /></span>
  401.  </p>
  402.  <p>
  403.     <label>City:  </label>
  404.     <span><input type="text" name="friend_city1" value="" size="40" class="common fcField" /></span>
  405.  </p>
  406.   <p>
  407.     <label>State:  </label>
  408.     <span><input type="text" name="friend_state1" value="" size="40" class="common fcField" /></span>
  409.  </p>
  410.  <p>
  411.     <label>Zip:  </label>
  412.     <span><input type="text" name="friend_zip1" value="" size="40" class="common fcField" /></span>
  413.  </p>
  414.  <p>
  415.     <label>Email Address:  </label>
  416.     <span><input type="text" name="friend_email1" value="" size="40" class="common fcField"/></span>
  417.  </p>
  418.  <p>
  419.     <label>Telephone No.:  </label>
  420.     <span><input type="text" name="friend_telephone1" value="" size="40" class="common fcField"/></span>
  421.  </p>
  422.  
  423. </div>
  424. <div class="commonBlock icsFormBody formPersonal">
  425. <p>
  426.     <label>Name:  </label>
  427.     <span><input type="text" name="friend_name2" value="" size="40" class="common fcField"/></span>
  428.  </p>
  429.  <p>
  430.     <label>How are they related to you:  </label>
  431.     <span><input type="text" name="friend_related2" value="" size="40" class="common fcField" /></span>
  432.  </p>
  433.  <p>
  434.     <label>Address:  </label>
  435.     <span><input type="text" name="friend_address2" value="" size="40" class="common fcField" /></span>
  436.  </p>
  437.  <p>
  438.     <label>City:  </label>
  439.     <span><input type="text" name="friend_city2" value="" size="40" class="common fcField" /></span>
  440.  </p>
  441.  <p>
  442.     <label>State:  </label>
  443.     <span><input type="text" name="friend_state2" value="" size="40" class="common fcField" /></span>
  444.  </p>
  445.  <p>
  446.     <label>Zip:  </label>
  447.     <span><input type="text" name="friend_zip2" value="" size="40" class="common fcField"/></span>
  448.  </p>
  449.  <p>
  450.     <label>Email Address:  </label>
  451.     <span><input type="text" name="friend_email2" value="" size="40" class="common fcField" /></span>
  452.  </p>
  453.  <p>
  454.     <label>Telephone No.:  </label>
  455.     <span><input type="text" name="friend_telephone2" value="" size="40" class="common fcField" /></span>
  456.  </p>
  457.  
  458. </div>
  459. <div class="commonBlock icsFormBody formPersonal">
  460. <b>Please complete the following information to the best of your knowledge:</b>
  461.  
  462.  <p>
  463.     <label>A)  List Occupational / Employment History Related and Special Training and Ministry Experience</label>
  464.     <span><input type="text" name="list_occupational" value="" size="40" class="common fcField" /></span>
  465.  </p>
  466.  
  467.  <p>
  468.     <label>B)   List Church Involvement and Extracurricular Activities (Boy Scouts, Vacation Bible School, Sports, etc.)</label>
  469.     <span><input type="text" name="list_church" value="" size="40" class="common fcField" /></span>
  470.  </p>
  471.  
  472.  <p>
  473.     <label>C)   What Are Your Educational And Professional Goals?</label>
  474.     <span><input type="text" name="goals" value="" size="40" class="common fcField" /></span>
  475.  </p>
  476.  
  477.  <p>
  478.     <label>D)   Why Do You Wish To Participate In This Program?</label>
  479.     <span><input type="text" name="wish_perticipate" value="" size="40" class="common fcField" /></span>
  480.  </p>
  481.  
  482. </div>
  483. <div class="commonBlock icsFormBody formPersonal">
  484.     <h3>Please write the degree(s) you have obtained below.</h3>
  485.    
  486.     <table class="simplr_text">
  487.         <tr>
  488.           <th>Name of School/College</th>
  489.           <th>State</th>
  490.           <th>Degree</th>
  491.           <th>Date of Completion</th>
  492.         </tr>
  493.         <tr>
  494.             <td><input type="text" class="tabledegree" name="college_name1" size="35"/></td>
  495.             <td><input type="text" class="tabledegree" name="college_state1" size="35"/></td>
  496.             <td><input type="text" class="tabledegree" name="degree1" size="35"/></td>
  497.             <td><input type="text" class="tabledegree" name="degreecompletion1" size="35"/></td>
  498.         </tr>
  499.        
  500.         <tr>
  501.             <td><input type="text" class="tabledegree" name="college_name2" size="35"/></td>
  502.             <td><input type="text" class="tabledegree" name="college_state2" size="35"/></td>
  503.             <td><input type="text" class="tabledegree" name="degree2" size="35"/></td>
  504.             <td><input type="text" class="tabledegree" name="degreecompletion2" size="35"/></td>
  505.         </tr>
  506.        
  507.         <tr>
  508.             <td><input type="text" class="tabledegree" name="college_name3" size="35"/></td>
  509.             <td><input type="text" class="tabledegree" name="college_state3" size="35"/></td>
  510.             <td><input type="text" class="tabledegree" name="degree3" size="35"/></td>
  511.             <td><input type="text" class="tabledegree" name="degreecompletion3" size="35"/></td>
  512.         </tr>
  513.        
  514.     </table>
  515.    
  516. </div>
  517. <div class="commonBlock icsFormBody formPersonal">
  518.     <p>
  519.     <label>Years in Ministry:  </label>
  520.     <span><input type="text" name="ministry_year" value="" size="40" class="common fcField" /></span>
  521.  </p>
  522.  <p>
  523.     <label>Military Service: </label>
  524.     <span><em class="attend_service"><input type="radio" value="Yes" name="military_service">
  525.     Yes
  526.     <input type="radio" value="No" name="military_service">
  527.     No</em>
  528.     </p>
  529.     <p>
  530.     <label>If Yes, what branch(s)? </label>
  531.     <span><input type="text" name="military_service_branch" value="" size="40" class="common fcField"/></span>
  532.  </p>
  533. </div>
  534. <div class="commonBlock icsFormBody formPersonal">
  535.     <p>
  536.     <label>Please give a brief statement about your relationships with your family Mother, Father, Siblings, Children, etc.</label>
  537.     <span><input type="text" name="relationships_description" value="" size="40" class="common fcField"/></span>
  538.  </p>
  539.     <p>
  540.     <label>Where are you employed l? </label>
  541.     <span><input type="text" name="employed_place" value="" size="40" class="common fcField" /></span>
  542.  </p>
  543.  <p>
  544.     <label>Monthly Salary? </label>
  545.     <span><input type="text" name="salary" value="" size="40" class="common fcField" /></span>
  546.  </p>
  547.  <p>
  548.     <label>How much did you earn last year? </label>
  549.     <span><input type="text" name="earn_lastyear" value="" size="40" class="common fcField"/></span>
  550.  </p>
  551. </div>
  552. <div class="commonBlock icsFormBody formPersonal">
  553.     <p>
  554.     <label>How do you plan on paying for your education? </label>
  555.     <span><input type="text" name="paying_for_education" value="" size="40" class="common fcField" /></span>
  556.  </p>
  557.  
  558.  
  559. <p>
  560.     <label>Do you have friends and possible supporters of your educational goals that would assist in covering costs of material, books, and tuition including the cost of shipping the course materials to you? (Please explain) </label>
  561.     <span><input type="text" name="assist_covering_costs" value="" size="40" class="common fcField"/></span>
  562.  </p>
  563.    
  564.     <p>
  565.     <label>What degree Program are you currently interested in?   </label>
  566.     <span><input type="text" name="interested_degree" value="" size="40" class="common fcField"/></span>
  567.  </p>
  568.  
  569.  <p>
  570.     <label>Are you interested in the Ordination Program?  </label>
  571.     <span><em class="attend_service"><input type="radio" value="Yes" name="ordination_program">
  572.     Yes
  573.     <input type="radio" value="No" name="ordination_program">
  574.     No</em>
  575.     </p>
  576.  
  577.  <p>
  578.     <label>Signature</label>
  579.     <span><input type="text" name="signature" value="" size="40" class="common fcField" /></span>
  580.  </p>
  581.  
  582.  <p>
  583.     <label>Print Name</label>
  584.     <span><input type="text" name="print_name" value="" size="40" class="common fcField" /></span>
  585.  </p>
  586.  
  587.  <p>
  588.     <label>Date </label>
  589.     <span><input type="text" name="current_date" value="" size="40" class="common fcField" /></span>
  590.  </p>
  591. <p><input type="submit" name="submit" value="Submit" class="wpcf7-form-control wpcf7-submit fcSubmit" /></p>
  592.  
  593.  
  594.  
  595. </form>
  596. </div>
  597.        
  598.     </div>
  599. </div>
  600. <?php //get_footer();
  601. ?>
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