COMMISSION ON CHAPLAINS

Preliminary Chaplain Endorser Application

Short Form

Use this form if this form is your first official contact with the FBFI Endorsing Agency

You must use this form if you are enquiring about or seeking endorsement for chaplaincy. DO NOT complete the “Request for Endorsement, Long Form” until you have been instructed to do so.

PERSONAL INFORMATION: (This information must be provided even if you filed the form, “Preliminary Chaplain Endorser Application, Short Form.”)

Date: Click here to enter a date.

Last Name:	First Name:	Middle Name:

Home Address:	Street:	City:	State:	Zip

How long have you lived at this address?	If fewer than 10 years, please give former address.

Previous Address: Street	City	State	Zip

Previous Address: Street	City	State	Zip

Previous Address: Street:	City:	State:	Zip

Home Phone: Work Phone: Cell Phone: E-Mail:

Social Security Number: Date of Birth:

Driver’s License Number:	State Issued:

U.S. Citizen? Yes No

Marital Status: (check all that apply)

Single Married	Widowed Divorced Separated Remarried

If married, wife’s name: _

Wedding Anniversary:

Current occupation:

Employer: Employer’s phone number: Employer’s e-mail address:

Employer’s address: Street	City	State	Zip

Area of Interest:

Military:

Civilian:

Do you have prior military service? If so, what branch? Dates of service: From to

Number of months enlisted: Number of months commissioned:

Rank and Grade (E-1; E-2; 0-1; 0-2 etc.): Did you receive an honorable discharge? Yes No

Have you been or are you now endorsed by another Endorser? Yes No

If yes, state the reason you are seeking a new Endorser.

Provide your current Endorser’s contact information.

Has your theological position changed since your initial endorsement, or has the theological position of your Endorsing Agency changed? Yes No

If “yes,” what changed?

Have you ever served in law enforcement? Yes No

Agency: Dates of service: From to

Do you have prior employment or volunteer service in a civilian agency that has or seeks chaplains? Details:

Before you are accessioned into the chaplaincy, you will have to report any legal citations, including traffic citations, civil legal actions against you including bankruptcy and the status of all outstanding financial obligations. Any such matter in your life will require a “moral waiver: by the military branch or civilian agency to which you are applying for chaplaincy and must be fully disclosed to your endorser who will be required to acknowledge in writing that the disclosure has been made and that endorsement is granted with full awareness.

Do you have any outstanding debts, past criminal record, or past moral indiscretion? Yes No

If yes, please explain.

EDUCATION:

Have you ever been expelled from an educational institution? Yes No

If so, explain the circumstances:

College which you are attending or from which you graduated:

Major(s):	Degree(s):

Dates Attended: From to

Other College you attended or from which you graduated: City State

Major(s):	Degree(s):

Dates Attended: From to

Seminary you are attending or from which you graduated: City State

Major(s):	Degree(s):

Dates Attended: From to

Other: City State

Major(s):	Degree(s):

Dates Attended: From to

Other: City State

Major(s):	Degree(s):

Dates Attended: From to

ORDINATION:

Date of ordination or expected date of ordination:

Ordaining church:

Address of ordaining church:	Street City	State	Zip

If not a Baptist church, explain.

MINISTRY EXPERIENCE:

Number of years of professional ministry experience completed, or plans to obtain professional ministry experience:

List previous ministry assignment/involvement:

Name of church:

Address: Street	City	State	Zip

Dates:

Position:

Duties:

Status:

Name of church:

Address: Street	City	State	Zip

Dates:

Position:

Duties:

Status:

Name of church:

Address: Street	City	State	Zip

Dates:

Position:

Duties:

Status:

Name of church:

Address: Street	City	State	Zip

Dates:

Position:

Duties:

Status: *Select One

CHURCH MEMBERSHIP:

Where is your current church membership?

Name: Phone:

Address: Street	City	State	Zip

Pastor: E-mail:

Home church, sending church (the local church to which you will be accountable as a chaplain):

Name: Phone:

Address: Street	City	State	Zip

Pastor: E-mail:

RECOGNITION: (use separate sheet, if necessary)

List any societies, boards and professional memberships:

List any honors you have received:

REFERENCES:

Your Pastor:

Name:

Address: Street	City	State	Zip

Phone:	E-mail:

One person who has encouraged you to become a chaplain:

Name:	Relationship:

Address: Street	City	State	Zip

Phone:	Email:

The references you have given will be contacted by the FBFI, and the information gathered will be considered during the processing of your application.

Affirmation:

I affirm the following:

I have full assurance of my salvation. Yes No

I believe that God has called me to the ministry. Yes No

I am seriously considering the chaplaincy. Yes No

PLEASE SUBMIT COMPLETED ELECTRONIC APPLICATION AND ATTACHMENTS TO:

FBFI Commission on Chaplains

2801 Wade Hampton Blvd.

Suite 115-165

Taylors, SC 29687

OR: info@fbfi.org