Clergy License Renewal Form

THE EPISCOPAL DIOCESE IN VERMONT

LICENSED CLERGY ANNUAL REPORT FOR CALENDAR YEAR 2021

AND REQUEST FOR LICENSE RENEWAL

The following constitutes my Annual Report as prescribed by Canon III.9.7(a) and is submitted to support my request that my license to function in the Diocese of Vermont be renewed for the calendar year 2022.
Last Name:
First Name:
MI:
Title:
Place of Canonical Residence:
Mailing Address:
City:
State:
Zip Code:
Home Phone:

Area Code Phone Number
Cell Phone:

Area Code Phone Number
Email Address: *
Occupation or Profession:
Business Contact Information (if any):
Spouse/ Partner Full Name:
Regular Place of Worship:
Date of Most Recent Safe Church Training: (Please note current training is required in order to be licensed, meaning a certificate for the full basic training within the last five years and subsequent re-certification every three years.

Month Day Year
Date
A Letter Of Good Standing From My Bishop Is Included With This Report Or Was Sent To The Bishop Of Vermont On:

Month Day Year
Date
My Most Recent Background And Public Records Check Was Completed On:

Month Day Year
Date
The following is a narrative of my occasional ministries during the last 12 months, including place, frequency, type of service, and, if recorded in a parish register, where. This list includes all supply celebrating, preaching, teaching, consulting or any other service in which I represented myself as a priest.:
I have no reportable occasional ministry, which I explain below:
I am available for supply:

Yes No
Other comments or requests:
Please Enter Your Name Here in Lieu of Signature:
Form Completion Date

Month Day Year
Date
Please Note: Your request for license renewal for the calendar year 2021 must be received by January 31, 2022.
Should be Empty: