Notarized Disclosure Form
Applicant Name:
Email address:
District: [__] AP [__] CM [__] HI [__] MV [__] NR [__] SS [__] SM [__] TV [__] TR
Ministerial Relationship Being Requested: [__] Local Pastor [__] Associate Membership [__] Elder [__] Deacon
General Instructions:
The Candidate is responsible for uploading completed Form and any attachments to the appropriate registrar(s) as directed by the requesting registrar.
Document should be completed not more than 12 months prior to the required interview
Part I: Legal History
(¶ 310.2, 324.12, 346.2, 347.2(a) and 347.3(a)of The Book of Discipline, 2020/2024)
Have you ever been convicted of a felony? [__] Yes [__] No
Have you ever been convicted of a misdemeanor? [__] Yes [__] No
Have you ever been accused in writing of sexual misconduct or child abuse? [__] Yes [__] No
If you answer “yes” to any of these questions, attach an explanation.
Part II: Chargeable Offenses
Have you read ¶2702 of The Book of Discipline 2020/2024? [__] Yes [__] No
Are you chargeable according to ¶2702 of The Book of Discipline 2020/2024? [__] Yes [__] No
If you answered yes, attach an explanation.
Part III: The Christian Life
Do you agree, for the sake of the mission of Jesus Christ in the world and the most effective witness of the gospel, and in consideration of your influence as a clergy person, to make a complete dedication of yourself to the highest ideals of the Christian life as set forth in “Our Doctrinal Heritage,” “Our Doctrinal Standards and General Rules,” “Our Theological Task,” and the “Social Principles,” ¶103-105, ¶160-166 of The Book of Discipline, 2020/2024? [__] Yes [__] No
Part IV: Signature I hereby certify that all the information I have provided is true and accurate.
Signature Date
Subscribed to and sworn before me on this _______________ date of ________________ 20____.
Notary Public Signature
Please submit to: [__] The Office of Clergy Services via ClergyServices@holston.org [__] DCOM