Chaplain’s Application

Join Our Network

If you are a law enforcement or hospital chaplain, join our network now!
Use your skills and compassion to support law enforcement and health care workers as they service the public.
$99 non-refundable application fee.

Step 1 of 8

12%

Bypass The Fee

Contact Information

Title(Required)

First(Required)

Middle

Last(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Home Phone(Required)

Cell Phone(Required)

Email Address(Required)

Fax Number

What is the best way to contact you in case of emergency?

Upload Your Image(Required)

Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.

PERSONAL INFO

Marital Status(Required)

Married

Divorced

Widowed

Single

Spouse’s Name

Date of Birth(Required)

MM slash DD slash YYYY

Race(Required)

Religion(Required)

Language Fluency: (List all)(Required)

Have you ever been convicted of a felony offense or do you currently have a felony charge pending in any state or country?

Yes

What case?

CHAPLAINCY INFO

Do you currently hold a position as a Chaplain?(Required)

Yes

Select Position

Paid

Volunteer

Full-time

Part-time

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Please check off which kind of facility you’ve worked with:(Required)

Police

Sheriff

Correctional Facility

Hospital

Military

Other (please detail)

If Other

Please list all agencies you’ve worked with as a chaplain:

Agency List(Required)

Agency

Dates served

End of Service

Contact information for agency

Contact person in agency(Required)

Contact's Phone(Required)

Please detail your Chaplaincy Training/Certification: (please attach copies of certification to application):(Required)

Drop files here or

Max. file size: 100 MB.

EMPLOYMENT INFO

Company Name(Required)

Company Phone(Required)

Job Title(Required)

Employment Location(Required)

Contact at Work(Required)

Contact’s Phone(Required)

What days do you work?(Required)

Sun

Mon

Tue

Wed

Thu

Fri

Sat

Day hours

Night hours

VEHICLE/LICENSE INFO

Do you have a vehicle for transportation?(Required)

Yes

Vehicle List

Make

Model

Color

Year

Plate #

License Number

State

Expiration of License

Is your driver’s license suspended or revoked?(Required)

Yes

How is your driving record?(Required)

Good

Fair

Bad

EMERGENCY CONTACT

Name(Required)

Email Address(Required)

Address(Required)

Home Phone(Required)

Cell Phone(Required)

REFERENCES

(One reference may be a family member, two must be non-family.)

Name(Required)

Phone(Required)

Relationship(Required)

Name

Phone

Relationship

Name

Phone

Relationship

name(Required)

I, , do hereby agree to all city, county, state and federal laws and requirements in regard to criminal background checks. I do understand that at any point in time I may be requested to update my criminal background check with no fees incurred to me and may be dismissed immediately if any changes have occurred since the prior criminal background check. If there is any change in my criminal background status, I will inform NCA.

Initials:

name(Required)

I, , do hereby agree to submit to random drug and alcohol testing to be performed at NCA’s request without notice. I do understand that failure to comply or if I am found to be under the influence of drugs and alcohol, it will be grounds for immediate dismissal.

Initials:

name(Required)

I, , do hereby agree to keep all matters discovered during the course of my chaplaincy work absolutely confidential. Privileged communication shall be regarded as highly confidential material and will only be revealed with the consent of the person involved. I agree to refrain from disclosing information in verbal, written, or electronic form. Confidentiality will be maintained within the limits of the law. I will not be held to confidentiality in the event of current child abuse or neglect, intended suicide or homicide, or the threat of bodily injury to self or danger or others.

Initials:

AGREEMENT AND SIGNATURE

I, the Volunteer Chaplain Applicant, do hereby certify that all of the information provided by me for the purpose of applying to become a volunteer chaplain or continued service as a volunteer chaplain is true and complete to the best of my knowledge. I understand that any false statements may end consideration of my volunteer activities with the National Chaplains Association, or may be cause for ending my volunteer role with NCA..

Applying to become(Required)

Service as a(Required)

Name (printed)(Required)

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Division of Motor Vehicles

Dear Sir or Madam:

Please send a copy of my Drivers Abstract. I understand that since this abstract is for membership in a non-profit organization (National Chaplains Association), there will be no fee for it.

Thank you,

Select state

thank you name(Required)

My Driver’s License Number is

My NJ Driver’s License Number is:(Required)

Select state

Name:(Required)

Address:(Required)

Enclosed please find a copy of my Driver’s License.

Select state

Upload Copy of License(Required)

Drop files here or

Max. file size: 100 MB.

Price(Required)

Price:

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

Application Fee

This application fee of $99 is non-refundable and does not guarantee acceptance into the organization.