Board of Directors Nomination Form

Please also consider me for other offices/positions(Required)
Mailing Address(Required)
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List place(s) of ministry in previous 10 years with dates (including current):
Place of Ministry
List previous offices or positions held in APC or other chaplaincy cognate associations with names and dates of service:
Identify courses, seminars, and symposia you have attended (A) or presented (P) that support your qualifications including dates:
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Identify 2 persons who could attest to your interest, qualifications and abilities, including contact information. At least one of these persons should be able to speak about your skills in the area you are applying for (i.e., if you are applying for Treasurer, this person would know about your budget and finance skills.) The committee may contact your references.(Required)
Place of Work
* In order to be considered for nomination each statement below MUST be initialed. *

Association of Professional Chaplains

Conflict of Interest Policy

The Association of Professional Chaplains (APC) is dedicated to promoting quality chaplaincy care through advocacy, education, professional standards and service to its members. The integrity of APC, and the activities it undertakes, depends on the avoidance of conflicts of interest, or even the appearance of such conflicts, by the individuals involved in those activities.

At the same time, APC recognizes that its members have significant professional, business and personal interests and relationships. Therefore, APC has determined that the most appropriate manner in which to address actual, potential or apparent conflicts of interest is initially through liberal disclosure of any relationship or interest which might be construed as resulting in such a conflict. Disclosure under this Conflict of Interest Policy (“Policy”) should not be construed as creating a presumption of impropriety or as automatically precluding someone from participating in an APC activity or decision-making process. Rather, it reflects APC’s recognition of the many factors that can influence one’s judgment and a desire to make as much information as possible available to other participants in APC related matters.

Any individual involved in an APC leadership role or decision-making process has an obligation to disclose any conflicting or potentially conflicting personal, professional or business interests he or she may have, directly or indirectly, with the affected role or decision. Potentially conflicting interests may relate to the APC’s programs and services (e.g., educational courses) or its operations (e.g., contracts with third parties). In the event an officer, director, member of a task force, working group or other committee (collectively, referred to herein as “committee members”) or state leader determines he or she has a conflict of interest on a particular matter, he or she shall disclose the conflict to APC’s Board of Directors or to the other committee members, as applicable.

In addition, participants in APC leadership roles are obligated to disclose the positions they hold or relationships they have with other organizations or entities that may conflict, directly or indirectly, with their APC roles. They also have an obligation to disclose any significant financial interest in, or other relationship with, an entity having a “commercial interest” in the activity. A commercial interest may exist not only where the entity’s products or services are under consideration by APC, but also where the entity’s products or services are in competition or potential competition with those under consideration. By the disclosure of such interests, other participants will have the opportunity to take potential biases into consideration. In addition, the Board of Directors (or, as applicable, committee members and state leaders) will be in a better position to determine whether the participant may have an interest in conflict with the interests of APC.

To help assure full disclosure of any actual or potential conflicts of interest, all participants in APC leadership roles, including APC’s officers, directors, committee members and state leaders must comply with this Policy and annually sign and submit a disclosure form (a copy of which is attached hereto) (i) acknowledging that he or she is aware of and has read the Policy; and (ii) disclosing the information described above. If, subsequent to any such annual disclosure (but prior to execution of a new annual disclosure form), an APC officer, director, committee member or state leader becomes aware of a relationship required to be so disclosed, that officer, director, committee member or state leader shall promptly make the required disclosure by submitting a revised disclosure form identifying the organization, business, group, entity, etc., and describing the nature of the relationship.

It is the responsibility of the disinterested members of the Board or, as applicable, committee members or state leaders, to interpret and apply this Policy. And, inasmuch as the Policy is stated in general terms, the Board or its designee(s) should use their best judgment in doing so.

Conflict of Interest Disclosure Form

I affirm that the following are all of my (including my immediate family and household1) material business, financial and organizational interests and affiliations which are or could be construed to be reasonably related to the interests, leadership roles and programs of the APC:
Please complete the following. If you have no information to list, please note “None.”
Please list any memberships on boards, offices held, employment or consulting arrangements or other affiliations you have had within the previous 12 months (or reasonably expect to have within the next 12 months) with any organization, business, group, agency or other entity that has done business with or potentially competes with the APC, or that you reasonably believe may do business with or compete with the APC.
Please list any material ownership interests (including stock options but excluding indirect investments through mutual funds and the like) in any entity that has a commercial interest in any activity, contract or matter directly related to the activities of APC (just the fact of ownership must be reported, and not the actual amount of such holdings).
Please list any leadership roles or positions you have held (e.g., board member, committee member, chair, president, advisor, contributor) in any organization, business or other entity that involves or may be perceived to compete with or be contrary to the interests of APC.
Please list any other activities, positions or interests you engage in or hold or anticipate engaging in or holding, which reasonably could be perceived to conflict with the interests of APC.
I have read, understand and agree to the terms of APC’s Conflict of Interest Policy and will take actions as deemed necessary or appropriate by the APC Board of Directors to manage the Conflict of Interest. To the best of my knowledge and belief, the information reported above is complete and accurate, and I am not aware of any other personal or professional position(s) or interest(s) or activities in which I am, or am about to be, engaged that reasonably may be anticipated to conflict with the interests of APC.
After clicking the “Submit” button below, your application will automatically be sent to the APC office and you will receive a confirmation e-mail with your form answers. Please keep a copy for your records.
1 For purposes of this disclosure form, the term “immediate family or household” refers to an individual’s spouse, minor child, or other person with whom such individual directly shares income.
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