1513 Nostrand Avenue, Brooklyn New York 11226 Tel. (718)287-5309

C.A.I.C.A. STATE OF NEW YORK

1513 Nostrand Avenue, Brooklyn New York 11226 Tel. (718)287-5309

Ethics & Disciplinary Committee

Apostle Vernon SeniorName ______

PresidentLast First M. I

Phone Number ______Email ______

Board Members

Elder Louise MclartyAddress______

Instructor

______Apt #______

Bishop Deleta Levy

DirectorCity ______State ______Zip______

Missionary Judine Wells

SecretaryD.O.B ______Place of Birth______

Elder Rosemarie Wilson

Secretary

US CitizenLegal Resident

Evangelist Sherma Senior

Recruiter

SS # ______Green Card# ______

Marital Status:Single Married Separated DivorcedWidowed

Name of spouse (if applicable) ______

Name and ages of children (if applicable)

NameAgeNameAge

______

______

______

Emergency contact person & phone number______

What Ministry would you prefer working for?

HospitalPrisonsPolice Dept. Fire DeptOthers

In a short paragraph describe what you expect to gain from our organization

______

______

Have you ever been convicted of any crime?YesNo

If YES please explain:

______

______

Highest Level of education completedHigh SchoolGEDCollege

Have you attended a Bible Institute?YesNo

If YES, provide Name, Location & Tel #

How many years completed?______

Any other Christian training

______

Work Information

Employer’s Name ______Phone number______

Address ______

Occupation ______

Number of Years ______

Supervisor’s Name______

Work Schedule

______

Church Information

Name & Address of Church

______

Phone #______Pastor’s Name______

How long have you been a member of this church?______

Have you accepted Jesus as your personal Savior?YesNo

Have you been baptized in water?YesNo

Have you been baptized by the Holy Spirit?YesNo

What ministries are you currently involved in at your church?

I hereby attest to the above information, with the understanding that any misleading or false information will result in the immediate rejection of this application or termination of membership.

xx

SignatureDate

X

Print Name

All requirements are to be agree upon before signing

A non-refundable International donation processing fee is due upon completion and submission of this application. The donation is non-refundable if you do not attend the classes. All Chaplains badges is the property of C.A.I.C.A and MUST be return if at any time you desire that you do not wish to continue with this Organization. All Chaplains are to be expected to attend schedule appointment for measurement of uniforms. All Chaplains uniforms are to be worn upon chaplain’s missions ONLY. All Rules and Regulations are expected to be followed by all Chaplains. If any Chaplains can not comply by these rules and regulations, then this Organization in not for you.

To be filled out by applicant’s Pastor

Is the applicant a member in good standing?YesNo

If NO, please explain: ______

______

______

How long has the applicant been a member of the Church? ______

Ministries applicant is involved in______

Is member faithful and responsible to the church?YesNo

If member status changes, would you inform us immediately?Yes No

Pastor’s Comments

xx

Pastor’s SignatureDate

References

Please Submit 2 references with attached reference letters.

Name:______

Tel. #:______

Address:______

How long have you known each other:______?

Relation:______

Name:______

Tel. #:______

Address:______

How long have you known each other:______?

Relation:______

Office Use Only

Background checkPassFail

Comments: ______

Reference CheckPassFail

Pastor Contact VerificationPassFail

ApplicantAcceptedRejected

If Rejected why?______

______

______

______

______

Approval by:

X

Apostle Vernon Senior

President & Founder