Ccsw Personal Disclosure Form printable pdf download

Ccsw Personal Disclosure Form

CCSW P

ERSONAL

ISCLOSURE

ORM

Please Note: This form will become part of your permanent ministry

record in the Christian Church (Disciples of Christ) in the Southwest.

Name [print legibly or type]: _____________________________________________________________

Last Name

First Name

Middle/Maiden Name

Other names by which I have been known: __________________________________________________

Circle One

Yes / No

Have you ever had your standing in the Christian Church (Disciples of Christ) terminated

or suspended?

Yes / No

Have you ever resigned or voluntarily relinquished your standing in the Christian Church

(Disciples of Christ)?

Yes / No

Have you ever had your standing reinstated in the Christian Church (Disciples of Christ)?

Yes / No

Are you currently the subject of disciplinary proceedings in the Christian Church

(Disciples of Christ)?

Yes / No

Have you ever been subject to disciplinary proceedings of another denomination or

church body in which you were accused of personal misbehavior or misconduct?

Yes / No

At any time in the last ten years has your driver’s license been suspended or revoked?

Yes / No

Have you ever been convicted or pled nolo contendere to a criminal charge involving

sexual conduct?

Yes / No

Have you ever been convicted of or pled nolo contendere to a felony?

Yes / No

Have you ever been accused of sexual misconduct (e.g. sexual assault, sexual

harassment, sexual exploitation) in any previous employment, as a volunteer, by criminal

authorities or in any other context?

For any “YES” response above, please describe the facts and circumstances. Use additional paper and

attach to this form.

Date:______________________

_________________________________________

Signature

FORM D

Page 1

– Apr 2015

Ccsw Personal Disclosure Form

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