App 15 Application: Self-Initiated Discontinuance as a Provisional Member (PE) (PD) (Âś327.6) Name:
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Address:
First
Middle
Last
______________________________________________________________________ Street
City
State
Zip
Best Contact # (______)________-__________ Birthdate: _________ _________ __________ [__] Cell [__] Home [__] Work Month Day Year Email: ______________________________________________________________________ Clergy Status: [__] Provisional Elder (PE) [__] Provisional Deacon (PD) District: [__] AP [__] CM [__] HI [__] MV [__] NR [__] SS [__] SM [__] TV [__] TR Charge: ______________________________________________________________________ Having prayerfully considered my current pastoral call, I believe that I am no longer called to serve as a Provisional Member in the United Methodist Church.
[__] [__]
I, therefore, voluntarily initiate a discontinuance of Provisional Membership. I understand that I must surrender my credentials to the District Superintendent
Reason for my discontinuance: [__] I do not wish to continue in the provisional process. [__] I am joining another denomination. [__] I with to terminate my membership and withdraw from the United Methodist Church. [__] I wish to designate _______________________________ United Methodist Church in the __________________________________ District of the Holston Annual Conference as the church to receive my transferred membership. [__] Having decided to remain in the United Methodist Church and seeking to continue service, I request that I be classified and approved as a Local Pastor in accordance with Âś316. __________________________ Signature
_________________________ Printed Name
___________________ Date
Please submit copies of this application to: [__] The Office of Clergy Services via ClergyServices@holston.org [__] Current District Superintendent
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District Superintendent - Office Use: Month Day Year [__] Pastor surrendered License to Preach: _________ _________ __________ [__] Pastor surrendered Certificate of Provisional Membership: _________ _________ __________ [__] Membership was transferred after consultation with Pastor: _________ _________ __________ [__] Circumstances that should be noted: ______________________________________________________________________ DS Mailed surrendered materials to Conference Secretary: Month Day Year [__] Pastor surrendered License to Preach: _________ _________ __________ [__] Pastor surrendered Certificate of Provisional Membership: _________ _________ __________ Conference Secretary - Office Use: Month Day Year BOM follow-up with Episcopal Office: _________ _________ __________ [__] Episcopal Office was informed of the Discontinuance and the reasons for discontinuance. [__] Record of action filed with Annual Conference Secretary Updated: 2020-11