Name *

First Name

Last Name

Date of Birth *

Applicants must be at least 21 years of age to be considered for chaplaincy.

MM

DD

YYYY

Primary Phone *

(###)

###

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Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Phone

(###)

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Are you ordained? *

This is not required in order to be a chaplain.

Yes

No

If so, when were you ordained?

MM

DD

YYYY

Do you have clinical training or institutional experience? *

This is not required in order to become a chaplain.

Yes

No

Have you ever been convicted of a felony or serious misdemeanor? *

Yes

No

Are you currently on probation or parole? *

Yes

No

The sheriff’s office requires a background check for anyone working within the jail system. Will you agree to a confidential release of such information? *

Yes

No

Reference 1 *

First Name

Last Name

Phone *

(###)

###

####

Reference 2 *

First Name

Last Name

Phone *

(###)

###

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Date of Submission *

MM

DD

YYYY