APPLICATION FOR CERTIFICATION

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THE AMERICAN CORRECTIONAL CHAPLAINS ASSOCIATION

APPLICATION FOR CERTIFICATION
BY THE ACCA
AS A CERTIFIED CORRECTIONAL CHAPLAIN

Attach Photograph2 x 2DATE:_______________________
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 _____

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