Community Chaplain Instructions: Please complete the application fully. Read and check the affirmation at the end of the form. Name Last * First * Middle * Other names used (Include maiden names) Phone # * Email * Address Street * City * State * Zip Code * Personal Information Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Present Age * Gender * Male Female Transgender Race Are you a Citizen of the U.S? * Yes No Do you possess a valid Driver’s license? * Yes No What Church/ Faith Organization do you belong to? * Do you hold a leadership role with the above organization? If So, Please describe * How many years have you been involved with that organization? * A pastoral (Leader) letter of recommendation is required for this application, are you able to provide a letter within the next 2 weeks? * Yes No How did you find out about the Community Chaplaincy? * Are you willing and able to commit to 20 volunteer hours per month? * Yes No Education * High School Diploma GED High School Information Name/Address * Yrs. attended * College/Trade information Name/Address * Yrs. attended * Course * Degree * Employment History Currently * Retired Employed Unemployed Employer 1 Address * Duties * Hire Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Reason for Leaving * Employer 2 Address Duties Hire Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Reason for Leaving Employer 3 Address Duties Hire Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Reason for Leaving Employer 4 Address Duties Hire Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Reason for Leaving Military Have you served in the military? * Yes No Branch of Service EOD Active Reserves Retired Discharged Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Type of Discharged Discharged Yes No Additional questions Have you ever previously applied for any position in the Baltimore Police Department or any other Law Enforcement Agency? * Yes No What Agency? What Position? When? Have you ever been a defendant in any court action * Yes No Please explain Are you now, or have you ever been a member of any organization, corporation, company, partnership, association, trust, foundation, fund, club, society, committee, political party, or any group of person whether or not incorporated, which engages in or advocates, abets, advises or teaches, or a purpose of which is to engage in, or advocate, abet, advise or teach activities intended to overthrow, destroy or alter or assist in the overthrow, destruction or alteration of the Constitutional form of Government of the United States or of the State of Maryland, or of any political sub division of either of them by revolution, force, violence or other unlawful means? * Yes No Please explain I hereby affirm that there are no intentional misrepresentation or falsifications in the foregoing statement and answers to questions. I am aware that should investigation disclose any such misrepresentation or falsifications, my application shall be rejected or if already employed my employment must be terminated. By entering your name into the signature field of this online application, you are legally signing the document. * Agree
