Va Form 10-0379 - Ecclesiastical Endorsing Organization Request To Designate Ecclesiastical Endorsing Official Page 3
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3ECCLESIASTICAL ENDORSING ORGANIZATION
REQUEST TO DESIGNATE ECCLESIASTICAL ENDORSING OFFICIAL (Con't)
12. DOES YOUR ORGANIZATION/RELIGIOUS BODY PRESENTLY HAVE AN AGENT AUTHORIZED TO
GRANT AND WITHDRAW ECCLESIASTICAL ENDORSEMENTS TO THE MILITARY?
YES
NO
12a. IF YES, GIVE THE NAME AND PHONE NUMBER OF THE AUTHORIZED AGENT
13. IS YOUR ORGANIZATION/RELIGIOUS BODY PART OF ANY OTHER ORGANIZATION/RELIGIOUS
BODY THAT PRESENTLY HAS AN AGENT AUTHORIZED TO GRANT AND/OR WITHDRAW
ECCLESIASTICAL ENDORSEMENTS TO EITHER THE MILITARY OR THE DEPARTMENT OF
VETERANS AFFAIRS?
YES
NO
13a. IF YES, GIVE THE NAME OF THE ORGANIZATION/RELIGIOUS BODY AND THE NAME OF THE
AUTHORIZED ENDORSING AGENT
14. TOTAL NUMBER OF CLERGY
15. TOTAL MEMBERSHIP OF THE
ORGANIZATION/RELIGIOUS BODY
16. TOTAL NUMBER OF:
(SELECT THE CATEGORY THAT MOST CLOSELY FITS YOUR ORGANIZATION)
A. CHURCHES
B. PARISHES
C. CONGREGATIONS
D. LOCAL ASSEMBLIES
NUMBER OF CLERGY
NUMBER OF CLERGY
CLERGY
CLERGY
BY SIGNING BELOW I ATTEST THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE FOLLOWING (A -G)
A. I am authorized by this organization to designate the endorsing official named in block 9a, to verify that
the organization meets the requirements listed in the instructions on the front of this form, and to verify the
answers to the questions below.
B. This organization meets the requirements listed in the instructions on the front of this form. If this
organization ceases to meet any of these requirements we will immediately notify the director, Chaplain
Service of the Department of Veterans Affairs.
C. Acceptance of an ecclesiastical endorsement by VA does not imply any approval by VA of the theology
or practices of a religious organization, nor does it obligate VA to employ the endorsed individual or any
other members of the organization.
D. VA's mission to provide health care to veterans is always paramount, and VA reserves the right to
restrict or prohibit within its facilities any practices that it deems detrimental to the health or safety of
patients.
E. Individuals endorsed by the organization shall function in a pluralistic environment and will support
directly and indirectly the free exercise of religion by all patients, family members and others authorized to
receive VA health care.
F. The documents accompanying this form are complete and accurately describe the organization's beliefs,
policies, and practices.
G. The organization, and individuals it endorses, agree to abide by all Federal, VA and VHA laws,
regulations, policies and issuances on the qualification, endorsement, selection, and employment of VA
chaplains.
17. SIGNATURE OF SENIOR PRESIDING OFFICIAL (LISTED IN ITEM 8)
Page 3 of 3
VA FORM
10-0379
DEC 2005
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