Name Date Home Address: Mailing Address: Phone Number: Email: Current Place of Worship: Ordaining Organization: Date of Ordination: Years of Ministry Experience: Ministry Experience 1 Dates: From To: Organization/Ministry: Contact Name: Organization Phone Number: Organization Email: Description of Duties: Ministry Experience 2 Dates: From To: Organization/Ministry: Contact Name: Organization Phone Number: Organization Email: Description of Duties: Ministry Experience 3 Date: From To: Organization/Ministry: Contact Name: Organization Phone Number: Organization Email: Description of Duties: Why are you interested in serving as a CPD Volunteer Chaplain? What experience do you have counseling individuals? What ministry activities are you currently involved in? Current Pastor/Priest/Imam/Elder/Deacon: Name: Contact Information (Phone&Email): May we Contact them? Yes No Please provide the dates of any of the below ministry roles in which you have served in the past and or are presently serving. • Faith Leader at Place of Worship • Chaplain Specify: Military, FBI, Police, Fire, etc. • Counselor License / Certification: Population Served: Youth, Adult, Marriage, etc. • Youth or Children’s Ministry • Hospice • Administrative Support • Marriage & Family Ministry • Trainer Crisis Intervention Clinical Trauma Disaster Response Reference: Please list three (3) references we may contact (friends, business associates, etc.) Please do not include family members. You must have known the person for at least 1 year.Reference 1 Name of Reference 1 Contact Information Phone/Email of Reference 1 Relationship with reference 1 Length of Time Known reference 1: Reference 2 Name of Reference 2 Contact Information Phone/Email of Reference 2 Relationship with reference 2 Length of Time Known reference 2: Reference 3 Name of Reference 3 Contact Information Phone/Email of Reference 3 Relationship with reference 3 Length of Time Known reference 3: