Name Details

Please use your complete *legal* name. If you do not have a middle name, please indicate NA.
Example: Robert = Bob or Rob

 

Mailing Address

 

Phone Numbers

You must have at least one phone number where you can be reached.

 

Email Address

The email address you would like the Northern Lights Regional Office to use for *all* email from the Region.
If you do not already receive email from the Region's MailChimp distribution service, would you like your primary email address to be added on your behalf?

 

Vital Statistics

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Reason for Application

 

Previous In-Care Experience

 

Post-High School Education

 

Previous Employment

Please list your last three employers and your position beginning with the most recent.

Employer 1 | Most Recent

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Use today's date if you're still currently in this position.

Employer 2

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Use today's date if you're still currently in this position.

Employer 3

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Use today's date if you're still currently in this position.

 

Disclosure Statement

 

Release for Criminal Background Check

BACKGROUND CHECK AUTHORIZATION

By completing and submitting this form, "I certify that the above is true and accurate and that in my judgment there are no other facts or circumstances involving me or my background related to my being entrusted with the responsibilities of ministry in the Christian Church (Disciples of Christ). Further, I understand and an initial background check will be requested by the Northern Lights Region, at no cost to me, and that an additional background check will be performed, at my expense, before final approval for ordination, commissioning, or standing is given through the Office of Search and Call, a ministry of Disciples Home Missions and the Christian Church Disciples of Christ." (Current cost of later background check is $160.)


The Christian Church (Disciples of Christ) in the Northern Lights Region conducts initial background checks through the Praesidium company. When you submit this application, your contact information will be used to have an electronic background check authorization form sent to you by Praesidium. Please watch for that email within 24-48 hours of submitting this form. If you do not receive the email, please contact the office of the Northern Lights Region.


Signature

By pressing the "Submit" button, you acknowledge that you are accountable for the information submitted and that the answers to the questions above will be used, in part, to determine your qualification to participate in In-Care program of the Christian Church (Disciples of Christ) in the Northern Lights Region.