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Application: Request to Self-Defer
The decision made by the submission of this application has an impact upon the appointment making process. Therefore, this application should be filed within two weeks of the date of the interview at which you were approved for associate membership, provisional membership or full connection status with the annual conference.
Name:
______________________________________________________________________ First Middle Last Address: ______________________________________________________________________ Street City State Zip Best Contact # (______)________-__________ Birthdate: _________ _________ __________ [__] Cell [__] Home [__] Work Month Day Year Email: ___________________________________________________________________ Current Clergy Status: [__] Certified Candidate [__] Local Pastor [__] Provisional Elder [__] Provisional Deacon District:
[__] AP [__] CM [__] HI [__] MV [__] NR [__] SS [__] SM [__] TV [__] TR
Pastoral Charge: Interviewed by:
___________________________________________________________________ [__] Division of Elders [__] Division of Deacons [__] Division of LP / AM
Status approved:
[__] Provisional Elder [__] Full Elder [__] Provisional Deacon [__] Full Deacon
I was Approved on:
_____________ _________ __________ Month Day Year
[__] Associate Membership
Initial each of the following applicable items: [__] I recognize that on the above date I received approval for the indicated membership status. However, after
additional prayer and discernment I submit this Application for Self-deferral as of the date signed herein. On the back of this form, or on a separate sheet, I have written a detailed description for the reason(s) I seek self-deferral.
[__] I seek to defer the above-named relationship with the annual conference until a later date, and [__] I do / [__] I do not desire an appointment in the coming annual conference year. [__] I understand that by deferring I am not guaranteed an appointment in a future appointment season, unless I am a provisional member. [__] I understand that by deferring my Provisional or Associate Membership I will serve as a local pastor, should I request an appointment during this time. [__] I understand that by self-deferring my Full Connection membership that I will continue to serve as a Provisional Member, subject to provisional membership timeline requirements.
[__] I understand that I must re-interview with the appropriate Division and receive a new recommendation from
that Division prior to being presented to the Clergy Session for approval. A request for a subsequent interview will come through my DCOM that will make the recommendation for an interview to the BOM.
_____________________________________________________________________________________ Please submit copies of this application to: [__] Chair, Board of Ordained Ministry [__] The Office of the Bishop [__] Current District Superintendent
[__] Applicable: Chair, Division of Elder / Deacon / Associate Member [__] Director of Clergy Services via ClergyServices@holston.org Updated: 2021-11
Application: Request to Self-Defer
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[__] I understand that the Division may request that I resubmit interview materials and that if I do not reinterview during the next interview cycle, then I must resubmit all materials and undergo the complete interview process again.
Specific reasons for this application for self-deferral are as follows (attach additional pages as necessary): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ __________________________ Signature
_________________________ Printed Name
___________________ Date
_____________________________________________________________________________________ Please submit copies of this application to: [__] Chair, Board of Ordained Ministry [__] The Office of the Bishop [__] Current District Superintendent
[__] Applicable: Chair, Division of Elder / Deacon / Associate Member [__] Director of Clergy Services via ClergyServices@holston.org Updated: 2021-11