Retired-Inactive Clergy Report Form

The Christian Church (Disciples of Christ) of Mid-America

Retired-Inactive Clergy
Report Form

Please complete this form to update your Clergy records as a "Retired-Inactive" Disciples of Christ (DOC) Minister with Standing in the Mid-America (CCMA) Region. This helps the Region ensure that your Clergy records remain current. If you are an "Active" or "Retired-Active" Minister, please instead complete both the Standing Renewal Report Form and Professional Development Report Form for the respective reporting year.

Should you have any questions, please contact your Ministry Associate in the Springfield Regional Office at sgf@ccmadisicples.org. Thank you so much!

Date

Title*

Rev.Rev. Dr.Other

Full Name*

First NameMiddle NameLast NameSuffix

Preferred Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Gender

Ethnicity

Date of Birth*

Date

Status*

Retired-InactiveOther

Official Date of Retirement*

Previous Employment*

Please list the last Ministerial Site (Congregation/Organization/Institution) that you served as a Minister or Chaplain (or other Ministerial capacity).

Previous Employment Position/Title*

Please list the Position/Title held with your previous Ministerial Site (Congregation/Organization/Institution).

Previous Employment Beginning & End Dates*

Please list the dates that your previous employment began and ended.

Other Previous Employment Information (if applicable)

Are you currently a Member of a DOC Congregation within the Mid-America Region?*

YesNo

Name & Location of Congregation where Membership is held.*

Your Mid-America Regional Minister(s)*

Have you been previously Commissioned/Licensed?*

YesNo

Original Date Commissioned/Licensed*

Please list both the date that you were originally Commissioned/Licensed and the Denomination/Region that Commissioned/Licensed you.

Are you Ordained?*

YesNo

Ordination Date*

Date

Ordination Region*

If Ordained by another Denomination, please list the Disciples of Christ (DOC) Region that first recognized your Ordination.

Important Documents (if applicable)

The Mid-America Region will gladly store any important documents you want saved in your Clergy file. Please upload any applicable documents here. You are also welcome to take a picture of documents and text them to the Ministry Associate in the Springfield Regional Office at (417) 865-0850.

Additional Comments/Feedback (if applicable)

This field is optional.

Would you like the Regional Office to mail you a Standing Card for the reporting year?

Yes, please mail it to me at the address provided.Yes, please email it to me at the email address provided.No, thank you. I don't need one.

I acknowledge my "Retired-Inactive" status as an Ordained Minister with Standing in the Mid-America Region. However, should I at any time decide to again become "Active" in Ministry, I will contact my Regional Minister or Ministry Associate in the Springfield Regional Office to begin the process of updating my Ministerial status and Standing. I understand that this will require me to complete annual standing forms and renew my Boundaries and Anti-Racism/Pro-Reconciliation Trainings (if they have not been taken in the past three years).