Retired Status Request

A board or associate certified chaplain whose BCCI certification and APC membership are in good standing and who is retired from professional chaplaincy may request retired status. Retired status applies to those who have substantially retired from the profession of chaplaincy and who work no more than 50% of the time within a year in professional compensated chaplaincy. Your certification or status with BCCI does not change, hence the use of the terms “Retired Board Certified Chaplain” and “Retired Associate Certified Chaplain.”

Complete this form and return it with the $120 annual APC membership dues payment (Nov. 1, 2016 to Oct. 31, 2017 membership year). Make checks payable to: Association of Professional Chaplains. Credit cards also accepted. Note: Maintenance of BCCI Certification fees, annual continuing education reports, five-year peer reviews and five-year spiritual/faith group endorsements are NOT required of retired board certified chaplains or retired associate certified chaplains.

Mail the completed application with the annual dues payment to: Association of Professional Chaplains, Inc., 2800 W. Higgins Rd., Suite 295, Hoffman Estates, IL 60169; Phone 847.240.1014; E-mail: [email protected]; FAX 847.240.1015.

Indicate category: Board Certified (Retired) or Associate Certified Chaplain (Retired) Salutation: Mr. Ms. Mrs. Chaplain Rev. Rabbi Father Sister Brother Imam Dr. Rev. Dr. CH (MAJ) CH (COL) Deaconess Pastor I. Name: Home Address: City/State/Zip: Home Phone: Religious Affiliation: E-mail: (please be specific) II. Last Employer: Position:

III. Date of Retirement (Month and Year): Date of certification as a board certified chaplain or status as an associate certified chaplain:

This form is to verify my retirement from full-time chaplaincy and my desire to become an associate certified chaplain (retired) or board certified chaplain (retired) in APC with full rights and privileges.

 Signature: Date:

Contact Information Release: All members are always included in the APC membership directory. In addition, contact information may also occasionally be released to outside organizations for purposes consistent with the mission of the association. You have the right to opt out of having your name and contact information released to outside organizations. By opting out, your name will not be released to any outside organization. I wish to opt out.

Charge: VISA MASTERCARD DISCOVER AMEX Amount: $ Billing Name: Billing Zip Code: CVV# (security code on back of CC) Card No. Exp. Date:

Revised: March 2017