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THE ASSOCIATION FOR CLINICAL PASTORAL EDUCATION, INC.
PUBLIC MEMBER DECLARATION OF QUALIFICATION
NAME OF PUBLIC MEMBER ___________________________________________________
CAPACITY:
_____Commissioner (commission)___________________________________________
_____Other (list)_________________________________________________________
By my signature, I attest that I am not
• employed by or associated with agencies or institutions affiliated with ACPE, Inc.;
• in service as an officer or staff member of a cognate ministry or chaplaincy group;
• an ACPE officer or employee, or
• the spouse, domestic partner, parent, child, or sibling of anyone in active practice in an accredited ACPE member center or any of the above.
____________________________________________
Signature of Public Member and Date