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Chaplaincy Program Application

  1. Contact Information
  2. Ecclesiastical Affiliation
  3. Are You Ordained*
  4. Education
  5. Chaplaincy Experience
  6. Check all that apply
  7. Additional Information
  8. 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.

  9. Additional Information

    Please include the following items with your application

  10. 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.

  11. Authorization Check Box*
  12. Leave This Blank:

  13. This field is not part of the form submission.