STATEMENT OF RECORD
1. Have you ever been charged with, accused of,
moved because of, or transferred to another position because of any sexual
misconduct or sexual harassment?
NO___________________YES__________________**
2. Have you ever been arrested or convicted of
any other offense (not sexual in nature)?
NO
__________________ YES _________________**
3. Have you ever filed for
bankruptcy or are you in arrears on any loans or credit cards? This includes student loans.
NO
__________________ YES _________________**
**If YES, give a full
explanation of the issues and results on the back of this form or in a letter
addressed to the Director of the Presbyterian Council for Chaplains and
Military Personnel.
***Note that the PCCMP may
execute a criminal and financial background check on any applicant
No application for
ecclesiastical endorsement will be processed without this signed and dated
document.
I certify that the above is
true and accurate. I understand that
falsification may result in immediate revocation of my endorsement.
SIGNED:_________________________________DATE______________________