Certification Commission Policy and Procedure Manual

APPENDIX 3-B cont’d
REGIONAL CERTIFICATION COMMITTEE
SAMPLE 2
SUPERVISORY CANDIDATE STATUS
REPORT OF ACTION
APPLICANT:
DATE:
ADDRESS:
TRAINING CENTER:
REGION:
SUPERVISOR:
PRESENTER:
APPLICANT’S REQUEST: Supervisory Candidate Status
COMMITTEE ACTION: __________ Granted
___________ Denied
______________________________________________________________________________
Documentation of Formal Requirements:
___ YES ___ NO Copies of college & seminary diplomas or transcripts or documentation of M Div
equivalency:
___ YES ___ NO Ordination or Commission to function in ministry/rabbinate by an appropriate
religious authority:
___ YES ___ NO Faith Group Endorsement (if applicable) (See Appendix 5 ACPE Ecclesiastical
Endorsement Conflict Resolution Policy)
___ YES ___ NO M.Div. or Equivalency.
___ YES ___ NO ACPE clinical membership and Accountability for Ethical Conduct Policy Report
Form:
___ YES ___ NO Completion of at least one unit of Supervisory CPE
Briefly evaluate the applicant’s written materials:
APPENDIX 3-B cont’d
2 Sample format, adapted from a form developed by ACPE Eastern Region
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