Partial Electronic — Partial Postal Mail/Fax Application

Which endorsement credential(s) are you are applying for? Please check all that apply.

Army
Navy
Air Force
Military Active Duty
Military Guard
Military Reserve
Military Seminarian
Civil Air Patrol
Veterans Affairs
Civilian Healthcare
Correctional
Workplace
Public School
Professional Pastoral Counselor
Certified Volunteer
Other  

1. Last Name     First Name     Middle Name  

2. Date of Birth      Soc. Sec. No.  

3. Home Address    City    State    Zip  
    Home Telephone    E-mail Address  

4. Office Address    City    State    Zip  
    Office Telephone    E-mail Address  

5. Are you an American citizen?  Yes  No
    (a) By Birth  (b) By Naturalization  Give Date  

*Items 6 - 9 For Military Applicants Only - all others skip to #10
6. Height      7. Weight   lbs.

8. Have you any physical defects?  Yes  No  
   If yes, briefly describe  

9. Do you have any disabilities?  Yes  No  
   If yes, briefly describe  

10. Have you ever been hospitalized for mental health concerns?  Yes  No  
    If yes, state the nature of illness(es)  

11. Have you ever been charged with or convicted of a criminal offense?  Yes  No  
    When?    Where?    Charges  

12. Have you ever committed a serious criminal act for which you were not charged?
    Yes  No  
    When?    What was it?  

13. Have you ever filed bankruptcy or had any serious financial problems?  Yes  No
    If yes, what date?  

14. What are your hobbies?  

15. Describe athletic ability:  

1. Marital Status:  Married  Single  Engaged  Separated  Divorced
    If married, date of marriage  

2. Spouse's Name  

3. Are you and your spouse living together?  Yes  No

4. Do you have a former living companion?  Yes  No
    If yes, please explain your history. [Note: A divorce is not an automatic disqualifier]
    

5. To what extent does your spouse share/support your interest in pastoral caregiving?
    

6. If you have children, list name and date of birth of each
    

7. List permanent emergency address and telephone number:
    ^{(Someone other than yourself or your spouse, who will always know your whereabouts)}
    Name  
    Address    City    State    Zip  
    Telephone  

1. Date of Salvation  

2. Date filled with the Holy Spirit  

3. When were you licensed?    By whom?  

4. When were you ordained?    By whom?  

5. Local church affiliation  

6. Have you previously applied for approval or endorsement?  Yes  No
    With whom?  
    What disposition was made of this previous application?
    

7. Ministerial experience, beginning with the present and working back:

1. College and Seminary training (please do not use initials for school names):

2. Have you had any clinical pastoral education/training?  Yes  No
  If so, how many units?  
  Where did you receive this clinical pastoral training?  

3. Other training, certifications, and memberships you have to prepare for chaplaincy:
    

1. Occupational experience (list most recent employers):

1. Previous Active Duty military service:
  Branch of Service    From   to   Grade  

2. Previous Reserve/Guard military service:
  Branch of Service    From   to   Grade  

3. If discharged, type of discharge you received  

4. If currently serving, what is the name of your unit?  
   Unit Address  

5. Have you ever been rejected for military service?  Yes No
   If yes, please explain:
   

6. I hereby grant permission to the CSC to review my military record
   when it sees a need to do so:  Yes No

General References (as indicated below, other than relatives). In order for us to obtain meaningful information from those who know you well enough to evaluate your ministry talents, list at least one in each category below: (List your church membership, if other than with your present pastor).

For the following section, please type your answers in the provided text box. There is no character limit on the boxes, so please do not feel constrained by the apparent size of the box.

1. Please discuss the following topics.
   a. Why do you desire to serve as a chaplain? Please explain your "call."
   

   b. How have you prepared, are you preparing, yourself for the chaplaincy?
   

   c. List, in order of priority, the major functions of a chaplain.
   

   d. Discuss controversial areas confronting the chaplaincy.
   

   e. What do you do most effectively as a minister?
   

   f. What do you do least effectively as a minister?
   

   g. Your concept of financial stewardship.
   

   h. Your understanding of pastoral care in a pluralistic setting.
   

2. Prepare a testimony of yourself (at least 200 words):
   

Please make sure all information requested in this form is complete and accurate.

Upon clicking "SUBMIT" below, you will be redirected to our Application Success Page. You should recieve a confirmation e-mail from us shortly. Your confirmation e-mail will include an attached 3-page PDF for your review and signature.

Your signed forms, along with 2 recent photos, transcripts, ordination certificate (if applicable), DD214 (for prior servicemembers), and either a $100 application/background investigation fee or proof of a current criminal background check should be mailed to:

If you would like to pay your application/background investigation fee via PayPal, please click the button below:

The information submitted with this form is true and accurate to the best of my knowledge.
My Name and Date below constitute the authentication of this form.

Applicant's Name  
Date Submitted