SECTION A: APPLICANT DEMOGRAPHICS
Choose one*
I am applying for Clinical Pastoral Education (CPE) (Complete Sections A, B, C) I am applying for CPE Supervisory Education (Complete Sections A and C)
Name*
First Name Middle Name Last Name
Address:
Email*
example@example.com
Phone Number*
FAITH GROUP AFFILIATION
Name of Faith Group/Religious Affiliation:*
Ordained:*
Yes No
EDUCATION
EDUCATION DEGREE DATE
College:
Graduate:
Graduate:
Other:
Center Supervisor Date
1.
2.
3
SECTION B: ESSAYS
1. Personal History. A description of your life story, including important events, relationships with people who have been significant to you, and the impact these events and relationships have had on your development. Describe your family of origin and your current family relationships.
2. Religious Development: A description of the development of your religious life, including events and relationships that affected your faith and currently inform your belief system.
3. Ministry Account: An account of an incident in which you were called to help someone, including the nature of the request, your assessment of the need, what you did, and a summary evaluation. If you had previous CPE, include information in pastoral conversation (verbatim) format.
SECTION C: RESUME & SIGNATURE
Resume/ CV: Attach a copy of your resume or CV:

Acknowledgement: I agree to comply: “CPEI is committed to providing an environment free from harassment and other forms of discrimination to its students, member, or credentialed persons. As such, CPEI will not tolerate harassment of any nature, which includes but is not limited to sexual harassment, unwelcome sexual advances, requests for sexual favors, and other verbal, or physical harassment of a sexual nature.”
I certify that all information in this application is factually true, complete, and honestly presented. I understand that I may be subject to disciplinary action, including admission revocation or program expulsion, should the information I have certified be false. I hereby give permission to the CPEI center to which I am applying to contact my references about matters pertaining to this current application.
I understand that my printed signature constitutes my electronic signature.
Upload CV/ Resume File
Printed Name:
Date
Month Day Year
Date
Should be Empty:

	EDUCATION	DEGREE	DATE
College:
Graduate:
Graduate:
Other:

	Center	Supervisor	Date
1.
2.
3

SECTION A: APPLICANT DEMOGRAPHICS

FAITH GROUP AFFILIATION

EDUCATION

SECTION B: ESSAYS

SECTION C: RESUME & SIGNATURE