Embassy University Registration

	A New Paradigm in Education
		Embassy University
	Giving the World a “New” Way of Life!

Email Address:	(this will be your username)
Password:
Confirm Password:
First Name:
Last Name:
Date of Birth:	Month Day Year
Gender:	Male Female
Birth order in your family:
Marital Status:	Single Married Divorced
Do you have a KJV Bible: Yes No
Will you faithfully meditate every night? As God gives me strength Yes

Street Address:
City:
State:
Zip:
Country:
Primary Phone:
Secondary Phone:
Church Background:

Name of person to verify your meditation:
(A person outside your family who will simply check your Rhema journal at lest once a month.)
Verifier Phone:
Verifier Email:

Registration Form