Successful Certification Verification
Certifications Chairs will complete this form upon the Candidate's Successful Certification Review or by Reciprocity.
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Person Submitting the Report:
First Name
Last Name
Email of Person Submitting the Report
*
example@example.com
Candidate's Information:
ENTER THE NAME BELOW AS TO HOW THE CANDIDATE DESIRES IT TO APPEAR ON THEIR CERTIFICATION CERTIFICATE.
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Successfully Certified or Approved by Reciprocity:
Certificate in Chaplaincy
Board Certified Associate Chaplain Review or Reciprocity
Board Certified Chaplain Review or Reciprocity
CPE Supervisor Review or Reciprocity (Completion of RSEC 1000)
CPE Supervisor Completion of RSEC 1000
CPE Training Supervisor Completion of TSEC 2000-2004
Associate Pastoral Counselor
Clinical Pastoral Counselor
Pastoral Counselor Supervisor-Educator
VERIFYING AFFILIATE ORGANIZATION REQUEST If the individual certified as a CPE Supervisor-Educator or Training Supervisor-Educator plans to open an CPEI Affiliate Organization, please check below.
YES-the individual plans to open an Affiliate Organization with CPEI.
NO-the individuals is not ready, but would appreciate information.
Submit
Should be Empty: