Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Home Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Home Email
example@example.com
Work Email
example@example.com
Is your home or work e-mail preferred?
I authorize my phone number and email to be published in the UCC yearbook.
Yes
No
Date of Birth
-
Month
-
Day
Year
Date
Place of birth
What is your marital status?
Single
Married
Divorced
Widowed
Spouse's Name
Anniversary Date
-
Month
-
Day
Year
Date
Educational History (college, graduate schools, seminary, regional training programs)
What authorization for ministry do you hold (please check all appropriate categories
UCC
DOC
Licensed
Dual Standing
Privilege of Call
Ordained
Commissioned Ministry
If Dual Standing, what is your Primary Denomination?
If Privilege of Call, what year was Privilege of Call granted?
If ordained, what year were you ordained?
If ordained, who was the ordaining body?
If commissioned, what year commissioned were you commissioned?
If commissioned ministry, what is your area of specialty?
What is the status of your ministry?
Active
Retired, currently active in ministry
Retired, not currently engaged in minisry
Leave of Absence
Other
If active, what is your called position and the name of church or setting with address
If you are on a leave of absence, when did leave begin?
-
Month
-
Day
Year
Date
In what ways have you maintained your covenant relationship with the Penn Central Conference, your Association, and the whole of the United Church of Christ during the past two years?
attended the Association meeting
attended the Annual Gathering
attended General Synod
attended an association or conference education event
attended association ministeriums
served on an association/conference/national board or committee:
interested in serving on a committee
Other
If other, please list below:
If you attended an association or conference education event, which did you attend?
If you served on an association/conference/national board or committee, which did you serve on?
If you are interested in serving on a committee, which one?
Please check any of the following that apply to you
I am planning to retire from active ministry
I have personal concerns that I would like to discuss with my Committee on Ministry or a PCC staff minister.
I have professional concerns that I would like to discuss with my Committee on Ministry or a PCC staff minister.
If planning to retire from active ministry, on what date are you planning to retire?
-
Month
-
Day
Year
Date
Please note any additional comments that you would like to share with the Committee on Ministry for your Association.
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