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2. Contact Information
4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Phone Number*
16. Email Address*
18. Ecclesiastical Affiliation
20. Church Name*
21. Address
23. Denomination/Judicatory/Association
25. Are You Ordained*

    1. Yes
    2. No
26. Date of Ordination
28. Years at Current Church
29. Total Years of Ministerial Experience
31. Education
33. College/University - Name and Location
34. Area of Study/Major
35. Degree Earned
37. Divinity School/Theological Education
38. Area of Study/Major
39. Degree Earned
41. Other Education - Name and Location
42. Area of Study/Major
43. Degree Earned
45. Chaplaincy Experience
47. Check all that apply

    1. Law Enforcement
    2. Fire/Rescue
    3. Military
    4. Hospital
    5. Hospice
    6. Other
48. Give Agency Name and Your Role
50. Additional Information
52. How did learn about the City of Havelock Chaplaincy Program
54. Why do you desire to serve as part of the Chaplaincy Program
56. Is there anything you would like to share with the City Manager or his/her designee?
58. References

    Please list two persons who have experienced your ministry and can speak to your gifts for the chaplaincy ministry. Please do not use family members.

60. Name
62. Address
64. Phone (home)
65. Phone (work)
67. Relationshiop
71. Name
73. Address
75. Phone (home)
76. Phone (work)
78. Relationship
80. Additional Information

    Please include the following items with your application

82. Copy of your Ordination Certificate*
83. Copy of your Diploma*
85. Agreement

    If I am accepted as an applicant for the City of Havelock Chaplaincy Program, I accept the following conditions:

    1. I will sit for an interview with the City Manger or designee
    2. I will submit to a background check
    3. I understand that I serve as a volunteer
    4. I have read the Chaplain's policy and will serve within the guidelines stated therein

    I acknowledge and affirm that the information provide by me in this application, including all attachments and exhibits, is true and correct to the best of my knowledge. I hereby authorize the City Manager or designee, to conduct a complete investigation of my background, character, reputation and fitness. This application shall constitute authority to all my past and present employers, to all educational institutions I have attended, to all religious institutions and other organizations to which I have been associated,  to all government entities (including criminal records check), and to any other person or entity having information about me, to fully disclose such information. I authorize the making and retention of photocopies or facsimiles of all such information, and request that photocopies or facsimile copies be accepted on the same basis as original documents.

87. Authorization Check Box*

    1. I accept this agreement
88. Date*
    Date

    Date
Leave This Blank:


90. 1. Receive an email copy of this form.
91. Email address

    This field is not part of the form submission.

92. Submit Submit and Print

* indicates a required field