Name
*
First Name
Last Name
My preferred pronouns
Phone
(###)
###
####
Email
*
Home Mailing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Birth Date: Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Date: Month
January
February
March
April
May
June
July
August
September
October
November
December
Ordination Date
MM
DD
YYYY
Racial/Ethnic Group
Name of local church:
Location of local church:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name of local church:
Location of local church:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name of local church:
Location of local church:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Estimated end date of interim:
MM
DD
YYYY
In what setting?
In what setting?
If "other," please describe:
My local membership is with (Name of Local Church, City, State):
I hold ministerial standing in (Association and Conference):
If so, please indicate the DOC Region or UC Canada Presbytery where standing is also held:
If so, please indicate the Denomination where standing is held:
Please identify the date, location, and topic/speaker of your most recently-attended boundary training:
How have you maintained your covenantal relationship with the United Church of Christ during the past year? Please check all that apply:
If "other," please describe:
Anticipated date of retirement:
MM
DD
YYYY
Is there anything in your life or ministry that you would like to share with Conference leadership?
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