License to Serve Application Form
License to Serve Application
PLEASE PRINT or TYPE Name ________________________________________________________ DOB __________________________ Address _______________________________________________________________________________________ Phone __________________________________ Email _______________________________________________ Canonical Resident of the Diocese of _________________________________ Ordained Priest Deacon Signature _____________________________________________________ Date __________________________
Do you wish to be licensed to serve in this Diocese? YES Have you completed anti-racism training in the last 5 years?
NO YES
NO
Have you completed the Safeguarding God’s Children and People Workshops in the last 3 years? YES Do you wish to be included on the Supply Clergy List made available to parishes? YES
NO
NO
If you have not had a background check done in the Diocese of Mississippi in the last three years, are you willing to have a background check done? YES NO (If so, an authorization form can be downloaded from our website at www.dioms.org under the Resources Tab, or sent to you by return mail.) Would you like to be included on the diocesan clergy listserve? YES
NO
All clergy are licensed to serve in the Diocese of Mississippi for ONE year and are responsible for renewing this license. The “Renewal of License to Serve” form is found on our website at http://www.dioms.org/clergy/list.html
Pease return this form by mail to: The Rt. Rev. Brian R. Seage P.O. Box 23107 Jackson, MS 39225-3107 or by email to: [email protected]
PLEASE PRINT or TYPE Name ________________________________________________________ DOB __________________________ Address _______________________________________________________________________________________ Phone __________________________________ Email _______________________________________________ Canonical Resident of the Diocese of _________________________________ Ordained Priest Deacon Signature _____________________________________________________ Date __________________________
Do you wish to be licensed to serve in this Diocese? YES Have you completed anti-racism training in the last 5 years?
NO YES
NO
Have you completed the Safeguarding God’s Children and People Workshops in the last 3 years? YES Do you wish to be included on the Supply Clergy List made available to parishes? YES
NO
NO
If you have not had a background check done in the Diocese of Mississippi in the last three years, are you willing to have a background check done? YES NO (If so, an authorization form can be downloaded from our website at www.dioms.org under the Resources Tab, or sent to you by return mail.) Would you like to be included on the diocesan clergy listserve? YES
NO
All clergy are licensed to serve in the Diocese of Mississippi for ONE year and are responsible for renewing this license. The “Renewal of License to Serve” form is found on our website at http://www.dioms.org/clergy/list.html
Pease return this form by mail to: The Rt. Rev. Brian R. Seage P.O. Box 23107 Jackson, MS 39225-3107 or by email to: [email protected]
