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ERCC Chaplaincy Application


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20012(c) Copy Right CERC and ERCC and ONA

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ERCC Chaplaincy Application

  1. 1. CERTIFIED EMERGENCY RESPONSE CHAPLAINS I.D. CARD APPLICATION/RENEWAL (Please Print Clearly)Name:_________________________________________________________________________________ (Last) (First) (M.I.) StreetAddress:__________________________________________________________________________City:_______________________________________________ State:________ Zip:________________E-mail Address:__________________________________________________________________________Phone: (_______)________________________________ CERC & ERCC HQ USE ONLYDate of Birth:____________________________________ (YYYY) (MM) (DD)Hair Color:___________________ Height:___________Eye Color:___________________ Weight:___________Signature:______________________________________ Date:_______________________________Submission Option (1): Print this form. Fill in all information. Mail completed and signed form, 2 passport photosto (ERCC) to: Chaplain (LTG) John D. Butler / ERCC/CERC P.O. Box 3332 Kinston, NC. 28502-3332Submission Option (2): Print form. Fill in all information. PDF or scan completed and signed form, and emailform and photo (JPEG format) to Option (1): Obtain passport photos from the Post Office, Walgreens, UPS, Wal-Mart or other commercialvendor. Cost is approximately $9.00 for 2 photos. Mail 1 photo with completed and signed form to the addressabove.Photo Option (2): Provide a JPEG photo via email. If you choose this option you MUST strictly adhere to thefollowing guidelines:  Take the photo against a plain white or off-white background  Photo must be full face, front view from top of head to just below the shoulders  Face in photo should have a natural expression; eyes open, mouth closed, not smiling  Wear a light colored (white preferred) button-up dress shirt/blouse with top button open  No clergy attire, uniforms, sunglasses, hats or scarves permitted