Chaplin Application Form

APPLICATION FOR CHAPLAINCY CERTIFICATION INTERVIEW

Print this Form, Fill Out and Mail to:
Certification Committee
New York State Council of Churches
1580 Central Avenue
Albany, New York 12205

As you fill out this Application, note carefully the requirements set forth in the “Chaplaincy Certification Criteria” booklet.”

NAME _____________________________________________________________________________________

ADDRESS _________________________________________________________________________________

CITY, STATE, ZIP ____________________________________________________________________________

PHONE: Home Work _________________________________________________________________________

DENOMINATION ____________________________________________________________________________

TYPE OF CHAPLAINCY FOR WHICH YOU ARE APPLYING:

_____ Department of Correctional Services

_____ Office of Mental Health Office of Mental Retardation and Developmental Disabilities

_____ Office of Children and Family Services

ORDINATION: (See Page 2, Section B, No.1 of booklet. Please state ordaining body and enclose a copy of your ordination certificate.)

________________________________________________________________________________________________________

OFFICIAL ECCLESIASTICAL ENDORSEMENT: (See Page 2, Section B, No.2 of booklet.

Give name of agency or official authorized by your denomination to endorse its clergy for chaplaincy positions. We will write this agency or person.)

NAME ___________________________________________________________________________________________________

ADDRESS _______________________________________________________________________________________________

Denominational yearbook and page in which you name appears: ______________________________________________________

FORMAL EDUCATION: (See page 2, Section B, No. 3 of booklet. Please enclose a copy of your post-secondary diplomas and have a transcript sent from the institution from which you received the diploma.)

School, Colleges, etc. Degree Field Date Awarded

________________________________________________________________________________________________________

If you do not have a Master of Divinity degree (see Section B, No. 3b) fill out and return Appendix B.

PASTORAL AND OTHER WORK EXPERIENCE: (List all forms with most recent first. See Page 2, Section B, No. 4 of booklet.)

Job Title Place Dates

_______________________________________________________________________________________________________

SPECIALIZED TRAINING FOR MINISTRY: (See Page 3, Section B, No. 5 of booklet. Please notify your training centers to send this information to the Committee.)

Training Centers Dates Number of Weeks/Months

(1) Name _____________________________________________________________________________________________

Address ________________________________________________________________________________________

Supervisor ______________________________________________________________________________________

(2) Name ____________________________________________________________________________________________

Address _______________________________________________________________________________________

Supervisor _____________________________________________________________________________________

WORK EXPERIENCES: (All forms. List most recent first.)

Job Title Place Dates

____________________________________________________________________________________________________

DISABILITY:

Do you have any physical or medical problems which would interfere with your ability to perform the job for which you are applying?

_____ Yes _____ No If “yes,” please explain on page 4.

REFERENCES: (One personal, one peer professional, one other professional, one lay person).

Name, address, zip, telephone Position/Profession

(1) _________________________________________________________________________________________________

_________________________________________________________________________________________________

(2) _________________________________________________________________________________________________

_________________________________________________________________________________________________

(3) ________________________________________________________________________________________________

________________________________________________________________________________________________

(4) ________________________________________________________________________________________________

________________________________________________________________________________________________

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is a cause of rejecting this application, or for decertification after I have been certified.

__________________________________________________________________________________________________

Date ______________________________________________________________________________________________

Signature APPENDIX A

Tell us why you want to become a chaplain and the particular “gifts and graces” you believe you will bring to this ministry. Use additional sheets as necessary. Please type.

APPENDIX B

If you do not have a Master of Divinity degree (see “Chaplaincy Certification Criteria” booklet, Page 2 Section 3. No3b), document for us an equivalent alternate program of education and training for ministry which has prepared you for chaplaincy service. List schools you have attended and courses of study you have completed. Attach relevant material (course descriptions and outlines, bibliographies, etc.) so we can evaluate this information. Please type.

Revised 11/97