Form 18 Declaration that a Retiring Local Pastor has met the criteria to be classified as a Retired Local Pastor (RL)
Name: ________________________________________________________________________________ Address: ______________________________________________________________________________ Phone: (____) ______-________ Email address: ______________________________________________ Church / Charge: _____________________________________________________________________________ District:
[__] AP [__] CM [__] HI [__] MV [__] NR [__] SS [__] SM [__] TV [__] TR
After examination, the DCOM of the _____ District certifies that the above named pastor has met the criteria to be considered a Retired Local Pastor (RL). Specifically this pastor has (check one) [__] Completed Course of Study (COS): __________________________________________ Date of COS Completion [__] Not completed COS, but was making adequate progress towards completion at the time of retirement. Upon retirement, the above named pastor will become a member at the following: Church: ___________________________________________________________________________ District: [__] AP [__] CM [__] HI [__] MV [__] NR [__] SS [__] SM [__] TV [__] TR
Signature:
I hereby certify that all the information I have provided is true and accurate.
__________________________________ __________________________ __________________________ DCOM Registrar: Signature Printed name Date
Please submit to: [__] The Office of Clergy Services via ClergyServices@holston.org [__] DCOM 1 of 1
Updated: 2020-11