Certification Appendix 2: Certification Commission Face Sheet
Name:
Requesting:
Meeting time/place:
Address:
Phone (h):
Phone (c):
E-mail
Present position
Present CPE Center:
Citizenship:
Date Supervisory Candidate/Associate Supervisor status expires
Faith group endorsement/accountability*
Faith group ordination/commissioning*
College degree* date
Graduate theological degree/equivalency* date
Other professional certifications:
Professional occupational background, starting from most recent position (dates, positions, descriptions):
CPE history [date(s), location, type of training, supervisor, number of students supervised] as Candidate and Associate:
Record of certification committee/Commission meetings/decisions [date(s), request, presenter, decision(s)]:
*See Attestation of Good Standing Form, Appendix 9
Attach additional documents here:
Attach additional documents here:
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