APPLICATION FORM

CONTRACT CHAPLAINCY

Pennsylvania Council of Churches

Section I   Personal 

Please print the following information  

__________________________________________                                     

                  Name                                                              Phone

_______________________________________________________________  

                  Address

 ____________________________   ____________________________

                  Email                                    Social Security Number

_______________________________         ___________ 

    Driver's License Number                         Issuing State

Are you ordained?  Yes / No                         Are you a college graduate?  Yes / No

Are you a seminary graduate?  Yes / No        Do you have a unit of CPE?  Yes / No

Have you ever been convicted of or pleaded guilty to a crime?   (Yes / No)   Attach explanation for “Yes”

Please answer sections II through V on the back of this page or an attachment.   Then read and sign the paragraph at the bottom of this page.  You may also attach a resume.  If any of the information requested in Sections II, III, or IV is provided on the resume, it may be omitted.   

 Section II Church Affiliation

Give the name of your denomination, the name of your Judicatory ( a sub-unit of a denomination), the name, address, phone number and fax number (if known) of the Judicatory Executive who would endorse you for this position.

 Section III Education

Give the name, location, major and degree from your college and seminary. Give the place where you took CPE (and /or other training).  If you do not have CPE, explain any other relevant experience.

 Section IV References

Give the names, address and phone numbers of two references that are not former employers or relatives.

 Section V Narrative Description

Give a narrative description of your qualifications for service as a chaplain and indicate why you wish to be considered for this service.  Note any special requirements such as geography, constraints on time. 

 Applicant’s Statement

The information contained in this application and attachments is correct to the best of my knowledge.  I authorize any references or churches listed in this application to give you any information (including opinions) that they may have regarding my character and fitness for chaplaincy work.  In consideration of the receipt and evaluation of this application by the Pennsylvania Council of Churches, I hereby release any individual, church, charity, employer, reference, or any other person or organization, including record custodians, both collectively and individually, from any and all damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply, with this authorization.  I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application.

Should my application be accepted, I agree to be bound by the policies of the Pennsylvania Council of Churches including the prohibition of sexual misconduct spelled out in the standards of conduct of the Council’s personnel policy.

 _________________________________     _____________  

Return to:          Pennsylvania Council of Churches

                         Office of Contract Chaplaincy                                   

900 South Arlington Ave.  Suite 100           

Harrisburg, PA 17109-5089

Phone: 717.545.4761                 Fax: 717.545.4765

Note: The following Authorization and Request for Criminal Records Check and Authorization to Release Information form must be completed and returned with application before employment or contract for services may be extended to applicant.