1211 South Glenstone Avenue
Springfield, MO 65804 USA
USA Fax: 417.862.0863
Email: studentinfo@globaluniversity.edu
Please clearly print all informationThis form is required for all applicants under the age of 18, study group students,
Assemblies of God ministerial credential applicants, or those who desire to be represented by other persons. Send
signed form to GU Student Services by mail, fax, or scanned email attachment (studentinfo@globaluniversity.edu).
Student ID #: __________________________________________ Date of Birth:
(Example: Jan/05/1987)
Email: Phone #:
Student Name:
______________________________ ______________________________
First Middle Last
Student Mailing Address:
P.O. Box or Street Address
City, State, and Zip Code
I authorize Global University to release all academic and financial records to and give authorization for my courses to
be ordered by the following (select all that apply):
Specified individual (spouse, parent, chaplain, pastor, etc.)
Name of individual:
Relationship to student:
Global University approved Study Group
Name of Study Group, Church, or Organization Study Group Account #
City, State, and Zip Code
Assemblies of God District Council
Name of District:
This authorization is in effect until such a time that I contact Global University in Springfield, Missouri and withdraw
my authorization in writing. I have read and understand Global University’s cancellation and refund policy as it pertains
to the specific level of courses (BSB, undergraduate, or graduate) that are being ordered.
Student Signature: __________________________
_________________ Date:
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