- (Please read the standards thoroughly before completing form.)
THE AMERICAN CORRECTIONAL CHAPLAINS ASSOCIATION
APPLICATION FOR CERTIFICATION
BY THE ACCA
AS A CERTIFIED CORRECTIONAL CHAPLAIN
| Attach Photograph2 x 2 | DATE:_______________________ |
NAME________________________________________________________________
ADDRESS_____________________________________________________________
PHONE (Office)___________(Home) __________ (Cell) _________E Mail____________________
FAITH GROUP (Include Denomination)_______________________________________
IF PRESENTLY EMPLOYED, BY WHOM?____________________________________
WHERE?___________________________________________________
TITLE:_______________________________________________________
DUTIES:______________________________________________________________
IF NOT EMPLOYED, WHAT IS YOUR STATUS AT THIS TIME?________________________________
NAME AND ADDRESS OF YOUR FAITH GROUP ENDORSING/DESIGNATING AGENCY FOR CORRECTIONAL CHAPLAINCY
NAME:______________________________________________________
ADDRESS:______________________________________________________
ARE YOU PRESENTLY ENDORSED? YES_____ NO_____
IF NOT, ARE YOU IN THE PROCESS FOR THIS? YES_____ NO_____
Certification Level Being Sought: ____________________________________________________
| EDUCATION:College_________________________ | Degree_______________________ | Year_______ |
| Seminary________________________ | Degree_______________________ | Year_______ |
| Postgraduate____________________ | Degree_______________________ | Year_______ |
| CPE ___________________________ | Unit 1 _______________________ | Year ______ |
| CPE ___________________________ | Unit 2 _______________________ | Year ______ |
| CPE ___________________________ | Additional Units ________________ | Years _____ |
Mail to: Rev. Norma Gillom, 2304 West 38th Ave. Pine Bluff, AR. 71603 … To print out form using Word click Form or to open a copy in Adobe Acrobat click here