UACCCI Training, Credentials, and Endorsement Information Form
This form is to be completed by all individuals receiving credentials for the first time and all those who renewing credentials. This form is also to be completed by all new and current students. Please complete this form in its entirety. All information is confidential and only information given authorization by applicant will be made public on our website or in our Membership Directory
Email address *
Today's Date *
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First Name *
Your answer
Last Name *
Your answer
Applicant Date of Birth
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Applicant Race *
Full Address *
Your answer
Country of Citizenship
Your answer
Phone Number *
Your answer
Are you a born again Christian according to Romans 10:8-10? *
Have you been water baptized by immersion? *
Martial Status *
Wedding Date *
Your answer
Date of Divorce *
Your answer
Education Status *
Earned Degrees and College Name *
Your answer
Veterans Status *
Which Branch Did you Serve *
Ministry or Counseling Center Name *
Your answer
Ministry or Counseling Center Full Address *
Your answer
Ministry or Counseling Center Phone Number *
Your answer
Applicant Position at Ministry or Counseling Center *
Your answer
What are you applying for? *
Minister Credentials Applying For *
Christian Counselor Credentials Applying For *
Chaplain Credentials Applying For *
Church Regularly Attending *
Your answer
Pastor Full Name *
Your answer
Church Phone Number *
Your answer
Church City and State *
Your answer
Personal Reference *
Your answer
Personal Reference Phone Number *
Your answer
Personal Reference Email Address
Your answer
Pastor Reference Name *
Your answer
Pastor Reference Email Address
Your answer
Pastor Reference Phone Number *
Your answer
Criminal History (Convictions do not necessarily eliminate anyone from credentials or entering into a training program) *
Required
If you have no criminal background put NA in the box. If you have a criminal background please indicate type, date, City and State of conviction. *
Your answer
Do you have any pending criminal court cases? *
Do you understand the UACCCI Doctrine, Code of Ethics and agree NOT to teach anything contrary? *
Do you understand ALL credentials are renewable each year and it is my responsibility to stay current? *
Would you like free advertising through our website listing your name and the type of ministry or business, services provided and business contact? *
Required
By providing my full name below I am attesting that all information in this form is correct to the best of my knowledge. *
Your answer
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