GENERAL INFORMATION

Name
Date of Birth
Gender Male Female
Social Security Number

PAID FULL-TIME   PAID PART-TIME   VOLUNTEER

PLEASE CHECK ALL THAT APPLY

MILITARY ENDORSEMENT

 INITIAL ENDORSEMENT

 MILITARY UPDATE ENDORSEMENT    VI/EXTENDED ACTIVE DUTY    REGULAR

ARMY ACTIVE DUTY  ARMY RESERVE  ARMY NATIONAL GUARD   NAVY ACTIVE DUTY  NAVY RESERVE

AIR FORCE ACTIVE DUTY   AIR FORCE RESERVE   AIR NATIONAL GUARD   CIVIL AIR PATROL

STATE GUARD   AUXILIARY CHAPLAIN   DRE  

CANDIDATE:  ARMY   NAVY   AIR FORCE   ( IF CANDIDATE, GIVE NAME AND LOCATION OF SEMINARY & DEGREE YOU ARE PURSUING.)

              SEMINARY                                                                            CITY                                     STATE                                 DEGREE

        

PLEASE CHECK ALL THAT APPLY

CORRECTIONS/CORPORATE/PUBLIC SAFETY ENDORSEMENT   

  C/C/PS UPDATE ENDORSEMENT

POLICE DEPT.   FIRE/EMS DEPT.   TRUCK STOP   RACE TRACK   TYPE:

COUNTY JAIL   STATE CORRECTIONAL

FEDERAL PRISON   AIRPORT   CORPORATE  

OTHER  

PLEASE CHECK ALL THAT APPLY

HEALTHCARE ENDORSEMENT   

  HEALTHCARE UPDATE ENDORSEMENT

HOSPITAL   CPE   HOSPICE   MENTAL HEALTH   MENTAL RETARDATION   CONVALESCENT/NURSING HOME

COUNSELOR IN MINISTRY -  TYPE:

OTHER  

PROFESSIONAL ASSOCIATION   LEVEL  

CONTACT INFORMATION

Please provide the following contact information:

WORK INFORMATION   
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
HOME INFORMATION    
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
PHONE & EMAIL       
Work Phone
Home Phone
Cell Phone
Home E-mail
Work E-mail

CITIZENSHIP AND MARITAL STATUS

Choose one of the following options:    If Other

 CITIZEN                        PLACE OF BIRTH  

NATURALIZED            DATE            PLACE   

IMMIGRATION STATUS   

AGE                    HEIGHT                WEIGHT  

CURRENT MARITAL STATUS      SINGLE   MARRIED    WIDOWED   SEPARATED    DIVORCED

PREVIOUS MARITAL STATUS        WIDOWED             DIVORCED

If divorced or separated, please give the reason and circumstances in the box below:

 

FAMILY INFORMATION

 

YOUR SPOUSE

NAME BIRTH DATE BIRTH PLACE SSN MARRIAGE
DATE

Does your spouse support you in this application?       Yes    No

 

YOUR CHILDREN

                    NAME                  SEX                 BIRTH DATE 
MALE      FEMALE                 
MALE      FEMALE                 
MALE      FEMALE                 
MALE      FEMALE                 
MALE      FEMALE                 
MALE      FEMALE                 
MALE      FEMALE                 
MALE      FEMALE                 
MALE      FEMALE                 
MALE      FEMALE                 
MALE      FEMALE                 
MALE      FEMALE                 

 

CHURCH INFORMATION

ORDAINING CHURCH

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code

DATE OF ORDINATION        

 

CURRENT CHURCH MEMBERSHIP

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code

 

NAME OF PASTOR     

NAME OF LOCAL SOUTHERN BAPTIST ASSOCIATION   

IS SPOUSE A MEMBER OF THE SAME CHURCH?   YES      NO    If not, please explain below.

                                                                                               

HAVE YOU PREVIOUSLY APPLIED FOR DENOMINATIONAL ENDORSEMENT?     YES     NO

 

 IF YES, WHAT DISPOSITION WAS MADE OF YOUR APPLICATION               

DO YOU CURRENTLY HAVE OR HAVE YOU HAD ENDORSEMENT WITH ANOTHER DENOMINATION?  YES  NO

 

IF YES, NAME OF DENOMINATION     

In making this application, I recognize the Chaplains Commission, SBC, of the North American Mission Board, SBC, to be the agency designated by the Southern Baptist Convention to endorse chaplains and counselors in ministry to military and civilian agencies and agree to cooperate with the Chaplains Commission, SBC, in carrying out its policies and programs.  I also recognize that it is the responsibility of the Chaplains Commission, SBC, to grant and/or to withdraw denominational endorsement.  Therefore, should I prove by temperament, disposition, attitude, conduct, or otherwise to unsuited for endorsement in the opinion of the Chaplains Commission, SBC, and should it decide that my denominational endorsement be withdrawn, I agree to abide by its decision.  I affirm the Baptist Faith and Message as currently adopted by the Southern Baptist Convention.

By typing my name below I am signing the statement.

SIGNATURE         DATE  

 


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