Application for Clinical Pastoral Education, ACPE

Special Instructions for Online Applicants: Before you hit the submit button at the bottom of the page, you must print a copy of this completed application form to sign by hand and then mail.

Your application will be reviewed when we have received all of the required materials, including the nonrefundable processing fee, photograph, written material, transcripts (if required), previous CPE evaluations (if applicable), and letters of recommendation.

(Required)





(Required)
(Required)
(Required)
(Required)
(Required)
(Required)
(Required)
(Required)
(Required)
(Required)
(Required)

Occupational History

(Required)
(Required)
(Required)

Educational History
(SIT and Residency applicants, please have your transcripts sent directly to us.)

References

Please download the Letter of Reference Form here. (You will need Adobe Reader to open this file.) Follow the instructions on the form and supply the forms to three references. List the names of the references below.

(Required)
(Required)
(Required)

Read Carefully Before Signing:

I certify that the information contained in this application and its attachments is true. I understand that falsification of information or incomplete statements will result in cancellation of this application. I agree that examination and verification of my employment and previous CPE education, except as it pertains to age, race, sex, color, creed, national origin, marital status or disability, may be made and used relative to my application status. I authorize my former CPE supervisors, employers, persons listed as references and other persons or organizations listed to provide this information and I release all concerned from any liability in connection therewith. I certify that as of the intended date of enrollment I will have graduated from an accredited high school or the equivalent and completed, in good standing, additional education and/or degrees as listed on this application and attachments. I understand that the application fee is not refundable.

Signature of Applicant (print first and then sign): ________________________________

Birth Date: ______________________ Social Security Number: ____________________

Today's Date: _______________________

 

Residency application materials may be read by the Director of Housestaff. Materials for successful residents are kept in the Housestaff Office according to the Standards of General Medical Education Programs.