Your FULL Legal Name: (First, Middle, Last) Your Email Address Postal Mailing Address County (not country) you live in: Daytime Phone: Evening Phone: Cell Phone: Website, if any: Date of Birth: Gender (M/F): Marital Status: What is your Occupation? What are your Hobbies? What is your highest education completed (high school, college, etc.)? What degree(s) do you hold, if any? Are You a Citizen of the United States? Have you ever been arrested or had criminal charges filed against you? (If Yes, please explain) Are You Currently Active Duty Military? If so, Branch Rank: Are You a Veteran of US Military Service? If so, Veterans Branch: Veterans Rank Type Discharge Dates of Military Service: If you are currently Active Military, or a Veteran, what is/was your Military Specialty (title, not MOS)? Are you currently active with any other Chaplains organization? If so, please list them List any previous Chaplains organizations you have been involved with Do you understand that the CCCA is a Non-Sectarian, Non-Denominational Christian organization? Have you and do you profess Jesus Christ as your personal Lord and Savior? What is your Christian affiliation or denomination? Are you currently in the Ministry? Are you, or have you been, Ordained? Ordained by (Church or Organization): How many years have you been ordained/active in ministry? If you have a Yahoo Profile ID, enter your Yahoo ID here: List a personal reference #1 (Name, Address, Email address, Phone number) List a personal reference #2 (Name, Address, Email address, Phone number) List a personal reference #3 (Name, Address, Email address, Phone number) Comments: including your skills, training, ministerial experience, military experience, etc. Applicant referred by: Do you affirm that the information provided above is truthful and accurate?