Va Form 10-0379 - Ecclesiastical Endorsing Organization Request To Designate Ecclesiastical Endorsing Official Page 2

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ECCLESIASTICAL ENDORSING ORGANIZATION
REQUEST TO DESIGNATE ECCLESIASTICAL ENDORSING OFFICIAL (Con't)
1. REQUEST DATE:
2. NAME OF ORGANIZATION:
3. ADDRESS
a. STREET (Include apartment or suite number)
b. CITY
d. ZIP CODE
c. STATE
AL
4. TELEPHONE NUMBER (Include area code)
5. FAX NUMBER (Include area code)
6. INTERNET SITE ADDRESS (If applicable)
7. E-MAIL ADDRESS (If applicable)
8. PRESIDING OFFICIAL(S)
a. NAME (Last, First, Middle Initial)
b. TITLE
9. INDIVIDUAL DESIGNATED TO ISSUE AND WITHDRAW ECCLESIASTICAL ENDORSEMENTS
(This cannot be an individual seeking to become a VA chaplain)
a. NAME (Last, First, Middle Initial)
b. TITLE
e. STATE
c. STREET (Include apartment or suite number)
d. CITY
f. ZIP CODE
AL
g. TELEPHONE NUMBER (Include area code)
h. FAX NUMBER (Include area code)
i. INTERNET SITE ADDRESS (If applicable)
j. E-MAIL ADDRESS (If applicable)
10. IS YOUR ORGANIZATION/RELIGIOUS BODY PRIMARILY ORGANIZED TO PROVIDE RELIGIOUS
MINISTRIES TO A LAY CONSTITUENCY?
YES
NO
11. HAS THE MEMBERSHIP OF YOUR ORGANIZATION/RELIGIOUS BODY AUTHORIZED THE
ORGANIZATION/RELIGIOUS BODY AS THEIR SOLE AGENCY FOR THE PURPOSE OF ENDORSING
INDIVIDUALS TO SERVE AS VA CHAPLAINS?
YES
NO
11a. IF NO, EXPLAIN
Page 2 of 3
VA FORM
10-0379
DEC 2005

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