Upper New York Conference Board of Ordained Ministry Application for Psychological Assessment

The District Committee on Ordained Ministry approves this application. Date

MonthDayYear
District Name
dCOM Chairperson
dCOM Chairperson's email
example@example.com
For Provisional Deacons and Elders: Date of interview with BOM

MonthDayYear
Date
Upper New York Conference Board of Ordained Ministry Application for Psychological Assessment
Please complete the following information:
Applicant’s Name
Mailing Address
Phone No(s) Mobile
Format: (000) 000-0000.
Church phone
Home phone
email
example@example.com
District
Local Church
My interview with the District Committee on Ordained Ministry is the following date:
(if uncertain, please give an estimated month and year)
Mentor’s Name
Mentor's Mailing Address
Mentor's Phone No(s) home
Format: (000) 000-0000.
Mentor's church phone
Mentor's cell phone
Mentor's email address
example@example.com
*To the Candidate:
In applying for this assessment, I understand I will receive a copy of the report and test data. I may distribute copies to whomever I wish. I also understand that all materials are kept in my personnel file in District Office files where I serve and are property of the Upper New York Annual Conference to review and then to use for nurture and discernment.
Candidate’s Signature
date

MonthDayYear
Date
To the Mentor:
I have discussed the Psychological Assessment process with this candidate and believe s/he is ready for this step.
Mentor’s Signature
date

MonthDayYear
Date
*Send a copy this application and $400 check payment to: Psychological Assessment Officer of the Board of Ordained Ministry

Rev. Nancy Adams, 3301 Watson Blvd., Endwell NY 13760

*Make the check of $400 payable to “Upper New York (UNY) Annual Conference”
Should be Empty:

Upper New York Conference Board of Ordained Ministry Application for Psychological Assessment

*To the Candidate:

To the Mentor: