PERSONAL:

TITLE/NAME:
MAILING ADDRESS (Street):
CITY, STATE, ZIP CODE:
WORK PHONE: HOME PHONE:
DENOMINATION / FAITH GROUP AFFILIATION:
ORDINATION / DATE:
ENDORSEMENT / DATE:
PASTORAL EXPERIENCE
(Required Minimum = 3 years, full-time equivalent):
PRESENT VAMC:
CURRENT MEMBER DVA/NBCA ? ( Yes / No ):
PRESENT VA POSITION / STATUS (FT, PT, Intermittent, etc..):
EDUCATION:
Schools Type of Degrees & Date Major
College(s):
Seminary:
Others:
OTHER CERTIFICATION(S):

CERTIFICATION REQUIREMENTS:

A. Current membership in good standings with the Department of Veterans Affairs National Black Chaplains Association. This includes payment of annual dues ($50.00 per year) for the current year which begins each October at the annual conference.

B. Two basic units of CPE, or equivalent. Persons entering the DVA prior to April 1998 may be considered under the grandfather system. The Certification Committee will determine qualifications and applicability.

C. One 8 ½ X 11 sheet of paper for each of the activities listed below:
· (1) Description of your current ministry in a clinical setting.
· (2) Your concept of “Team Ministry.”
· (3) Your understanding of "Pastoral Care.”
· (4) Your understanding of “Pluralism.”

D. Copies of certificates, programs, seminars, workshops, courses and all other evidence of Continuing Education Units (CEU’S) received, including awards, recognition’s, etc. in chaplain related education.

E. Examining Board will interview candidate(s) at specified time or at annual session.
General principles of pastoral care will be the highlight of the discussion. Candidate(s) will be notified if any requested information is missing, incomplete or insufficient prior to scheduling interview.

NOTE: The certification fee of $25.00 must accompany the completed application.

MAIL THREE (3) COPIES of the materials listed in C and D along with the

Application and fee(s) to: