Retired Life Member Status Request Form All board certified or associate chaplains in the Association of Professional Chaplains whose membership is in good standing and who are retired from professional chaplaincy may request retired life member status. Retired life member 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. Certification or status with BCCI does not change, hence the use of the terms “Retired Board Certified Chaplain” and “Retired Associate Certified Chaplain.” Once a life member, your dues are paid for life and your membership entitles you to all the regular benefits of membership. But more importantly, your retired life membership supports the ongoing work of APC, symbolizing your commitment to shaping the future of professional chaplaincy and the goals of APC throughout your retirement. 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.Retired life memberships may be pledged and paid over a period of one year. The designation will be established upon receiving the full $1,000. Member InformationIndicate certification type(Required) Board Certified Chaplain (Retired Life Member) Associate Certified Chaplain (Retired Life Member) Salutation(Required)Mr.Ms.Mrs.ChaplainRev.RabbiFatherSisterBrotherImamDr.Rev. Dr.CH (MAJ)CH (COL)DeaconessPastorName(Required) First Middle Last Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Phone Type(Required)HomeMobileWorkE-mail(Required) Last Employer Position Date of Retirement(Required) Month Day Year This form is to verify my retirement from full-time ministry and my desire to become an associate chaplain retired life member or board certified chaplain retired life member in APC with full rights and privileges.Signature:(Required) Date:(Required) Month Day Year Payment InformationNumber of Payments My $1,000 Retired Life Membership is being paid in full My $1,000 Retired Life Membership is being paid in two payments of $500 Payment Method Check Credit Card Invoice Information Please invoice me Please invoice my organization If paying by credit card, APC staff will be in touch to receive payment information. If paying by check, please make payable to Association of Professional Chaplains and mail to: Association of Professional Chaplains 2800 W. Higgins Rd., Suite 295 Hoffman Estates, IL 60169EmailThis field is for validation purposes and should be left unchanged. Δ
Association of Professional ChaplainsAssociation of Professional Chaplains
