BP-S677.039 CHAPLANCY APPLCATON NSTRUCTONS CDFRM - SEP 2001 U.S. DEPARTMENT OF JUSTCE FEDERAL BUREAU OF PRSONS APPLCANT NFORMATON The Bureau of Prisons welcomes the opportunity to employ experienced, credentialed ministers to serve as staff chaplains throughout its correctional facilities nationwide. The application'packet includes the following information: 1. Bureau of Prison Chaplaincy Services: An Overview 2. Qualification and Job Requirements for Chaplaincy 3. Application Forms A. Resume containing information by the brochure "Applying for a Federal Job" or Optional Application for Federal Employment (OF-612) B. Release of nformation Forms 1. Authorization for Release of nformation Form (SF 85P) 2. Authorization for Release of Medical nformation Form (SF 85P) C. Chaplaincy Candidate '~u~~lemental nformation Form (BP-S678) D. Ecclesiastical Endorsement for Chaplaincy Form (BP-S 679) E. Chaplaincy Candidate Certification and Authorization Form BP-S680)* F. Credit Release Authorization Form - See P.S. 3000.02 * Signature is to be witnessed before mailing n addition, the application must address all professional experience related to the position of chaplain. A certificate of ordination is required. A copy of all college and Master of Divinity or equivalent transcripts must be sent directly to the Central Office by the academic institutions. Submission of an incomplete application may delay possible employment. Please forward any change in address or telephone number. Once the applicant is found qualified, employment consideration will be based on the identified location preferences and chaplain staffing needs throughout the Bureau of Prisons. The applicant will be interviewed at the appropriate Regional Office for an announced vacancy in one of the Bureau's institutions. Mail all applicant forms, related materials and correspondence to the below listed address : Religious Services Branch Federal Bureau of Prisons, Room 512 320 First Street N.W. washington,-d.c. 20534
U.S. Department of Justice Federal Bureau of Prisons Religious Services Application Paclret
Bureau of Prisons Chaplaincy Services An Overview Backcrround The Bureau of Prisons (BOP) employs full-time chaplains in all of its facilities. The size of the chaplaincy team is generally determined by the number of inmates in the population and the complexity of the institution mission. The word "team" is key in that all BOP chaplains, regardless of their own faith orientation, are expected to minister as an effective pastoral team to an entire inmate population representing a wide variety of faith traditions -- or no faith at all. Chaplains must be willing to accommodate the free exercise of religion guaranteed by the First Amendment for all inmates. Accommodation means so much more than simple tolerance of the belief systems of inmates. t involves respect, appreciation and understanding of the faith traditions of inmates. n addition, it involves active assistance in providing opportunities and means necessary for inmates to be able to grow and mature spiritually within their own faith traditions. Chaplains are hired according to the Federal Personnel Manual for the 060 series, which establishes appointment criteria in the excepted service, established by the Office of Personnel Management. Chaplaincy is an excepted service appointment. Chaplaincy in the Bureau of Prisons is intended for professionally trained and experienced ministers. Because of the education and experience requirements, chaplaincy is not an entry level pastoral position. The starting grade is GS-12 for all staff chaplains. There are several GS-13 supervisory chaplain positions at designated institutions throughout the system. As wi-th all correctional workers in the BOP, a chaplain may retire with full benefits at 50 years of age after twenty years of service. Mandatory retirement occurs at the age of 57.years with 20 years of service. The Mission of Chaplaincv Services The mission of the Religious Services Department is to accommodate the free exercise of religion by facilitating opportunities to pursue individual religious beliefs and practices in accordance with the law, Federal regulations and Bureau of Prisons policy, and providing pastoral care to all (Effeclive March 2008)
Federal inmates. The staff chaplain shall provide religious worship, education, counseling, spiritual direction, support and crisis intervention to accommodate the diverse religious needs of inmates. When appropriate, the pastoral care and subject matter expertise may be extended to staff. The Goals of Chaplaincv Services n addition, the goals of chaplaincy can be summed up in these VTAL FUNCTONS, each with its attendant areas of responsibility. They are as follows: Ensure chaplains are accessible and approachable for inmates and provide sensitive pastoral care. Among the duties of the provision of pastoral care in the institution are: Leading worship services which are meaningful, appropriate, well-prepared and timely Helping to bring resolution to crisis situations involving inmates, staff, or their families Visiting all areas of the institution and being accessible and approachable Working collaboratively with the other chaplains on the team in all aspects of ministry Being advocates for the rights of inmates Ensure impartial religious leadership by providing resources and programs to accommodate the religious rights and divekse needs of inmates. Among the duties and responsibilities requiring this impartial leadership are: Determining that equitable and reasonable opportunities exist for worship, study and religious programs for all faith groups represented in the institution Providing supervision of religious inmate services ahd meetings Enabling faith groups to observe religious holy days and special religious observances Coordinating services, programs and activities provided by contractors and volunteers (Effective Mi~rcli 2008)
Utilizing the departmental budget to fairly and equitably meet the' religious needs of the inmate faith groups 3. Communicates the mission of the department. Among the duties and responsibilities by which the chaplain meets these management goals are: Being a ready resource for expert information to staff Communicating clearly and timely activities of the chaplaincy department Providing training programs and materials for staff and volunteers in new and/or unfamiliar issues of inmate religious beliefs and practices (Effcclivc March 2008)
QUALFCATONS AND JOB REQUREMENTS FOR CHAPLANCY Candidates will meet the following requirements for an excepted service appointment to the position of Chaplain in the Federal Bureau of Prisons. The application packet will be completed and all official documentation will be provided to the Central Office chaplaincy staff by the applicant prior to any consideration of candidacy. QUALFCATONS A. PERSONAL QUALFCATONS (1) Age: Ordinarily an initial appointment must be made prior to one's 37th birthday. The Department of Justice has granted an age requirement exemption for candidates of some faith traditions when a documented shortage exists of qualified candidates of those faith traditions who meet the maximum age entry provision of 5 U.S.C. S3307 and Public Law. (2) Religious Credentials: Applicants will be ordained clergy or members of ecclesiastically recognized religious institutes of vowed men or women. When ordination is not a part of the religious tradition, adequate documentation of the applicant's recognized religious and ministerial role within their faith communities is required. (3) Suitability: Applicants must be within the suitability guidelines established for areas of employment, financial and criminal history, intentional false statements or misrepresentation in the application, or moral turpitude. (4) Physical Standards: Applicants must successfully pass a pre-employment physical examination (including urinalysis). Following initial hire, as a condition of future employment, applicants must further pass a Physical Abilities Test (PAT). This is designed to measure the physical requirements necessary to perform the essential functions in a correctional setting, such as the ability to respond to emergencies. (5) RESDENCY REQUREMENTS: For three of the five years immediately prior to applying for a position, the applicant must have resided in the United States, worked for the United States overseas in a Federal or military capacity, or be a dependent of a Federal or military employee serving overseas. At the present time, processing non-citizens may take up to two years. Therefore, based on time constraints and institution need, the Bureau of Prisons is not currently accepting applications from (Effective March 2008)
non-united States citizens. B. PROFESS ONAL PREPARATON (1) Academic Requirements: Candidates must possess an earned bachelor's degree and the Master of Divinity degree from an Association of Theological Schools (ATS) accredited residential seminary or school of theology, or possess the equivalent educational credits described below. Official transcripts must be sent directly to the Central Office by the academic institutions. Equivalent educational qualifications means: An earned bachelors degree from an accredited college with at least 120 semester hours. Quarter hour credits will be converted to the semester hour equivalency using a 1.5 : 1 ratio. Successful completion of 80 semester hours or 108 quarter hours of graduate study which included or was supplemented by: 20 semester hours (27 quarter hours) of pastoral ministry (examples: homiletics, preaching, ministry, pastoral counseling, supervised ministry). 20 semester hours (27 quarter hours) in any combination of theology, ethics, and philosophy of religion. 20 semester hours (27 quarter hours) in religious history or world religions (The applicant will be able to demonstrate an understanding of religious pluralism). 20 semester hours (27 quarter hours) in the study of religious writings, including the study of languages in which sacred religious writings are written. (2) Experience: At least one full year of Clinical Pastoral Education (4 quarters), or two years (4174 hours)of full-time pastoral/spiritual leadership experience in a congregational or specialized ministry setting within the endorsing body after formal ministerial preparation. (3) Ecclesiastical Endorsements: The endorsement will attest to the applicant's suitability for correctional ministry, support for his/her candidacy and a clear assurance statement that the applicant has no present nor past legal or moral barrier to congregational ministry, nor to ministry to inmates of all faiths. The applicantf s relationsh-ip to the endorsing 'body must (Effective March 2008)
reflect a minimum two year association before endorsement. After evaluation of completed application packet documenting personal and professional qualifications, fully qualified candidates will be invited to an interview when a vacancy exists in an institution. Upon successful completion of pre-interview screening and panel interview, the warden of the institution makes a final recommendation for employment..candidate selection resides with the Regional Director. The legitimate business needs of the Bureau are always a factor in determining suitability for BOP chaplaincy. The religious/spiritual needs of the inmate population, as well as the candidate's professional preparation, are placement factors. That is to say, wherever possible, chaplains of diverse faith traditions will ordinarily be placed in an institution ahead of those of the same faith tradition. Applications of non-selected candidates or those awaiting a particular geographic preference will ordinarily expire after one year. nitial appointments are determined by the needs of the Bureau. Chaplains will ordinarily be placed in institutions having a reasonable number of inmates of their faith tradition (Protestant, Catholic, Jewish, Muslim, Buddhist, Native American, etc.). n the correctional environment, chaplains are required to work at least two evenings a week, and on their weekly traditional day of worship in order to maximize opportunities for inmate worship and programming. n addition chaplains are required to work the seasonal holy days of their faith traditions. Work schedules and days off for staff chaplains are determined by seniority. Because of the sensitive nature of the chaplaincy position, the processing of applications includes a thorough investigation of academic and ecclesiastical credentials. nconsistencies in documents will be vigorously pursued, in order to assure that chaplain candidates are'most representative of those called to correctional ministry. Chaplains are required to adhere to the Bureau of Prisons' Employee Standards of Conduct. (Effective March 2008)
1 General nformation Optional Application for Federal Employment - OF 612 You may apply for most Federal jobs with a rbsumb, an Optional Application for Federal Employment (OF 612), or other written format. f your rbsumb or application does not provide all the information requested on this form and in the job vacancy announcement, you may lose consideration for a job. Type or print clearly in black ink. Help speed the selection process by keeping your application brief and sending only the requested information. f essential to attach additional pages, include your name and job announcement number on each page. a lnformation on Federal employment and the latest information about educational and training provisions are available at www.usajobs gov or via interactive voice response system: (703) 724-1850 or TDD (978) 461-8404. Upon request from the employing Federal agency, you must provide documentation or proof that your degree(s) is from a school accredited by an accrediting body recognized by the Secretary, U.S. Department of Education, or that your education meets the other provisions outlined in the OPM Operating Manual. t will be your responsibility to secure the documentation that verifies that you attended and earned your degree@) from this accredited institution(s) (e.g., official transcript). Federal agencies will verify your documentation. For a list of postsecondary educational institutions and programs accredited by accrediting agencies and state approval agencies recognized by the U.S. Secretary of Education, refer to the U.S. Department of Education Office of Postsecondary Education website at http lwww ope.ed gov/accred~tat~onl. For information on Educational and Training Provisions or Requirements, refer to the OPM Operating Manual available at http lwww opm govl quai1f1cat1onslsec-ll/s2-e4 asp. f you served on active duty in the United States Military and were discharged or released from active duty in the armed forces under honorable conditions, you may be eligible for veterans' preference. To receive preference, if your service began afier October 15, 1976, you must have a Campaign Badge, Expeditionary Medal, or a service-connected disability. Veterans' preference is not a factor for Senior Executive Service jobs or when competition is limited to status candidates (current or former career or career-conditional Federal employees). Most Federal jobs require United States citizenship and also that males over age 18 born after December 31, 1959, have registered with the Selective Service System or have an exemption. The law generally prohibits public officials from appointing, promoting, or recommending their relatives. Federal annuitants (military and civilian) may have their salaries or annuities reduced. Every employee must pay any valid delinquent debt or the agency may garnish their salary. Send your application to the office announcing the vacancy. f you have questions, contact the office identified in the announcement. - - - How to Apply. Review the listing of current vacancies. 2. Decide which jobs, pay range, and locations interest you. 3. Follow nstructions provided in the vacancy announcement including any additional forms that are required. You may apply for most jobs with a resume, this form, or any other written format; all appllcations must include the information requested n the vacancy announcement as well as information required for all applications for Federal employment (see below): The USAJOBS website features an online rbsumb builder. This is a free service that allows you to create a rbsumb, submit it electronically (for some vacancy announcements), and save it online for use in the future. Certain information is required to evaluate your qualifications and determine if you meet legal requirements for Federal employment. f your resume or application does not include all the required information as specified below, the agency may not consider you for the vacancy. Help speed the selection process - submit a concise resume' or application and send only the required material. nformation required for all appllcatlons for Federal employment: Job Vacancy Specifics Announcement number, title and grade@) of the job you are applying for Personal lnformation Full name, mailing address (with zip code) and day and evening phone numbers (with area code) and email address, if applicable Social Security Number Country of citizenship (most Federal jobs require U.S. citizenship) Veterans' preference Reinstatement eligibility (for former Federal employees) Highest Federal civilian grade held (including job series and dates held) Selective Service (if applicable) Work Experience Provide the following information for your paid and volunteer work experience related to the job you are applying for: b job title (include job series and grade if Federal) b duties and accomplishments b employer's name and address b supervisor's name and telephone number - indicate if supervisor may be contacted b starting and ending dates (month and year) b hours per week b salary J.S. Office of Personnel Management NSN 7540-01-351-9178 OF 612 Previous edition usable 50612-101 Revised June 2006 Page 1 of 4 1
Education High School b Name, city, and State (Zip code if known) b Date of diploma or GED How to Apply (continued) Colleges or universities b Name, city, and State (Zip code if known) b Majors b Type and year of degrees received. (f no degree, show total credits earned and indicate whether semester or quarter hours.) Do not attach a copy of your transcript unless requested Do not list degrees received based solely on life experience or obtained from schools with little or no academic standards Upon request from the employing Federal agency, you must provide documentation or proof that your degree(s) is from a school accredited by an accrediting body recognized by the Secretary, U.S. Department of Education, or that your education meets the other provisions outlined in the OPM Operating Manual. t will be your responsibility to secure the documentation that verifies that you attended and earned your degree(s) from this accredited institution(s) (e.g., official transcript). Federal agencies will verify your documentation. For a list of postsecondary educational institutions and programs accredited by accrediting agencies and state approval agencies recognized by the U.S. Secretary of Education, refer to the U.S. Department of Education Office of Postsecondary Education website at http 1lwww.ope ed govlaccred~tat~onl. For information on Educational and Training Provisions or Requirements, refer to the OPM Operating Manual available at http llwww opm gov/qual~f~cat~onsl SEC-ll:s2-e4 asp. Other Education Completed School name, city, and State (Zip code if known) b Credits earned and Majors b Type and year of degrees received. (f no degree, show total credits earned and indicate whether semester or quarter hours.) Do not list degrees received based solely on life experience or obtained from schools with little or no academic standards Other Qualifications Job-related: b Training (title of course and year) b Skills (e.g., other languages, computer softwarelhardware, tools, machinery, typing speed, etc.) b Certificates or licenses (current only). nclude type of license or certificate, date of latest license, and State or other licensing agency b Honors, awards, and special accomplishments. (e.g., publications, memberships in professional honor societies, leadership activities, public speaking and performance awards) (Give dates but do not send documents unless requested) Any Other information Specified in the Vacancy Announcement Privacy Act Statement The U.S. Office of Personnel Management and other Federal agencies rate applicants for Federal jobs under the authority of sections 1104, 1302, 3301, 3304, 3320, 3361, 3393, and 3394 of title 5 of the United States Code. We need the information requested in this form and in the associated vacancy announcements to evaluate your qualifications. Other laws require us to ask about citizenship, military service, etc. n order to keep your records in order, we request your Social Security Number (SSN) under the authority of Executive Order 9397 which requires the SSN for the purpose of uniform, orderly administration of personnel records. Failure to furnish the requested information may delay or prevent action on your application. We use your SSN to seek information about you from employers, schools, banks, and others who know you. We may use your SSN in studies and computer matching with other Government files. f you do not give us your SSN or any other information requested, we cannot process your application. Also, incomplete addresses and ZP Codes will slow processing. We may confirm information from your records with prospective nonfederal employers concerning tenure of employment, civil service status, length of service, and date and nature of action for separation as shown on personnel action forms of specifically identified individuals. Public Burden Statement We estimate the public reporting burden for this collection will vary from 20 to 240 minutes with an average of 90 minutes per response, including time for reviewing instructions, searching existing data sources, gathering data, and completing and reviewing the information. Send comments regarding the burden statement or any other aspect of the collection of information, including suggestions for reducing this burden to the U.S. Office of Personnel Management (OPM), OPM Forms Officer, Washington, DC 20415-7900. The OMB number, 3206-0219, is currently valid. OPM may not collect this information and you are not required to respond, unless this number is displayed. Do not send completed application forms to this address; follow directions provided in the vacancy announcement(s). THE FEDERAL GOVERNMENT S AN EQUAL OPPORTUNTY EMPLOYER U.S. Office of Personnel Management Previous edition usable NSN 7540-01-351-91 78 50612-101 Page 2 of 4 OF 612 Revised June 2006
. -. ~ ~- -. - OPTONAL APPLCATON FOR FEDERAL EMPLOYMENT - OF 612. ~.. - Section A - Applicant nformation i 1. Job title in announcement 2. Grade(s) applying for 3. Announcement number - -. ~~ Form Approved. OMB. NO. 3206-0219 Use Standard State Postal Codes (abbreviations). f outside the United States of America, and you do not have a military address, type or print "OV' in the State field (Block 6c) and fill in the Country field (Block 6e) below, leaving the Zip Code field (Block 6d) blank,--_--_ - ~ -- -.... -- ~ ~ - ; 4a Last name 4b. First and middle names 5. Social Secur~ty Number 6a. Mailing address 6b. City 6c. State 6d. Zip Code 7. Phone numbers (include area code if within the United States of America) 7a. Daytime 7b. Evening : 6e. Country (if not within the United States of America) 1 8. Email address (if available) p-- -- -- ---! Section B - Work Experience i 1 -Describe your paid and non-paid workexperience related to the job for which you are applying. Do not attach-jobdescription., 1. Job title (if Federal, include series and grade) 2 From (mm/yyyy) 3. To ( ~~/YYYY) 4. Salary Per 5. Hours per week! 6. Employer's name and address 7. Supervisor's name and phone'number 7a. Name 7b. Phone 1 8. May we contact your current supervisor? Yes No : f we need to contact your current supervisor before making an offer, we will contact you first. 9. Describe your duties, accomplishments and related skills (if you need to attach additional pages, include your name, address, and job ' announcement number) -.--.- --. --. -.- -- -. - A Section C - Additional Work Experience 1 1. Job title (if Federal, include series and grade) 2. From (mm/yyyy) 3. To ( ~~/YYY) 4. Salary per 5. Hours per week $ 6 Employer's name and address 7. Supervisor's name and phone number 7a. Name 7b. Phone 8. May we contact your current supervisor? Yes No f we need to contact your current supervisor before making an offer, we will contact you first. 9. Describe your duties, accomplishments and related skills (if you need to attach additional pages, include your name, address, and job announcement number) U.S. Office of Personnel Management Previous edition usable NSN 7540-01-351-9178 50612-10 Page 3 of 4 OF 612 Revised June 2006
~ - ~. - - -- ~ ~- Section D - Education Upon request from the employing Federal agency, you must provide documentation or pmof that your degree(s) is from a school accredited by an accrediting body recngnized by the Secretary, U. S. Department of Education, or that your education meets the other provisions outlined in the OPM Operating Manual. t will be your responsibility to secure the documentation that verifies that you attended and earned your degree(s) frorn this accredited institution(s) (e.g.. official transcript). Federal agencies will verify your documentation. For a list of postsecondary educational institutions and programs accredited by accrediting agencies and state approval agenclas recognized by the U.S. Secretary of Education, refer to the U.S. Department of Education Ohice of Postsecondary Education website at hltp;lwaope.ed.go./iactreditationl. ( For information on Educational and Trainlng Provisions or Requirements. refer to the OPM Operating Manual available at http;~,opm,govlquai1fi~at1on~/sec-ill2-& asp. - Do not list degrees received based solely on life experience or obtained frorn schools with lfflle or no academic standards. 1. Last High School (HS)/GED school. Give the school's name, city, state, ZP Code (if known), and year diploma or GED received: 2. Mark highest level completed: Some HS n HSGED n Associate n Bachelor n Master n Doctoral n 3. Colleges and universities attended. Total Credits Earned Major(s) Degree (if any), Do not attach a copy of your transcript unless requested. Semester Quarter Year Received 3a. Name City State ZP Code 3b. Name City State Zip Code 3c. Name City - -- - - - -- State Zip Code Section E - Other Education Completed -- Do not list degrees received based solely on life experience or obtained from schools with little or no academic standards. -- - Section F - Other Qualifications.--. -..- -- ----. License or Certificate Date of Latest License or Certificate State or Other Licensing f. 2f..~... ~ -- - ~ -- - - - -. -.. - - -. Section G - Other Qualifications Job-related training courses (give title and year). Job-related skills (other languages, computer softwarelhardware, tools, machinery, typing speed, etc.). Job-related honors, awards, and special accomplishments (publications, memberships in professionallhonor societies, leadership activities, public speaking, and performance awards). Give dates, but do not send documents unless requested. -PAP -- Section H - General ~. - -- - -.~ la. Are you a U.S. citizen? Yes No + 1 b. f no, give the Country of your citizenship 2a. Do you claim veterans' preference? Yes No + f yes, mark your claim of 5 or 10 points below. 2b. 5 points -) Attach your Report of Separation from Active Duty (DD 214) or other proof. 2c. 10 points j Attach an Application for 10-Point Veterans' Preference (SF 15) and proof required. 3. Check this box if you are an adult male born on or after January 1st 1960, and you registered for Selective Service between the ages of 18 through 25 -+ 4. Were You ever a Federal civilian employee? Yes. NO -) f yes, list highest civilian grade for the following: 4a. Series 4b. Grade 4c. From (mm/yyyy) 4d. To (mm/yyyy) 5a. Are you eligible for reinstatement based on career or career-conditional Federal status? Yes No f requested in the vacancy announcement, attach Notification of Personnel Action (SF 50), as proof.. ~ 5b. Are youeligible under the CTAP'? yes 0 NO 0. - 'CTAP (nteragency Career Transition Assistance Plan): A participant in this plan is a current or former federal employee displaced from a Federal agency. To be eligible, you must have received a formal notice of separation such as a RF separation notice. if you are an CTAP eligible, normally you will be provided priority consideration for vacancies within your commuting area for which you apply and are well qualified... -- ~ --- ~ ~ Section - Applicant Certification -- certify that, to the best of my knowledge and belief, all of the information on and attached to this application is true, correct, complete, and made in good faith. understand that false or fraudulent information on or attached to this application may be grounds for not hiring me or for firing me after begin work. and may be punishable by fine or imprisonment. i understand that any information give may be investigated. 1 a. Signature b. Date (rnrn/~id/~~j/yj Previous edition usable NSN 7540-01-351-9178 OF 612 U.S. Office of Personnel Management 50612-10 Revised June 2006
Slandard Form 85P Revised September 1995 U.S. Office of Personnel Management 5 CFR Parts 731,732, and 736 Form approved: OM0 NO. 3206-0191 NSN 7540-01 -31 7-7372 85-1602 UNTED STATES OF AMERCA AUTHORZATON FOR RELEASE OF NFORMATON Carefully read this authorization to release information about you, then sign and date it in ink. Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my background investigation, to obtain any information relating to my activities from individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retail business establishments, or other sources of information. This information may include, but is not limited to, my academic, residential, achievement, performance, attendance, disciplinary, employment history, criminal history record information, and financial and credit information. authorize the Federal agency conducting my investigation to disclose the record of my background investigation to the requesting agency for the purpose of making a determination of suitability or eligibility for a security clearance. Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other sources of information, a separate specific release will be needed, and may be contacted for such a release at a later date. Where a separate release is requested for information relating to mental health treatment or counseling, the release will contain a list of the specific questions, relevant to the job description, which the doctor or therapist will be asked. Further Authorize any investigator, special agent, or other duly accredited representative of the U.S. Office of Personnel Management, the Federal Bureau of nvestigation, the Department of Defense, the Defense nvestigative Service, and any other authorized Federal agency, to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for assignment to, or retention in a sensitive National Security position, in accordance with 5 U.S.C. 9101. understand that may request a copy of such records as may be available to me under the law. Authorize custodians of records and other sources of information pertaining to me to release such information upon request of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any previous agreement to the contrary. Understand that the information released by records custodians and sources of information is for official use by the Federal Government only for the purposes provided in this Standard Form 85P, and that it may be redisclosed by the Government only as authorized by law. Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for five (5) years from the date signed or upon the termination of my affiliation with the Federal Government, whichever is sooner. Signature (Sign in ink) Full Name (Type or Print Legibly) Date Signed Other Names Used Social Security Number Current Address (Streel. City) State ZP Code Home Telephone Number (nclude Area Code) Page 8 ( 1
BP-A0660.012 MAR 99 U.S. DEPARTMENT OF JUSTCE FEDERAL BUREAU OF PRSONS AUTHORZATON FOR RELEASE OF NFORMATON NCC (National Crime nformation Center) CHECK hereby authorize a representative of the Federal Bureau of Prisons to obtain any information on my criminal history background. understand that this check must be done before am allowed to enter/serve at any Bureau facility. also understand that refusal to provide all necessary information may result in 1) denial of entry into a Bureau facility and 2) denial of volunteer/contract status. 1. Name (Last, First, Middle) 2. Address (Street address) (City, State, County, zip code) 3. Home Telephone Number (Area Code, Number) : 5. Citizenship (List the country you are a citizen of) : 6. Social Security Number: 7. Date of Birth (Month, day, year) : 8a. Sex: 8c. Height: Be. Color of Eyes: 8b. Race: Ed. Weight: of. Color of Hair: 9. Place of Birth (City, State, County), (List city, county and country if outside the U.S.A) 10. The above listed information is true and correct. Applicant's Signature 10a. Date PRVACY ACT NOTCE Authoritv for Collectins nformation: E.O. 10450; 5 USC 1303-1305; 42 USC 2165 and 2455; 22 USC 2585 and 2519; and 5 USC 3301 Purposes and Uses: nformation provided on this form w i l l be furnished to individuals in order to obtain information regarding activities in connection with an investigation to determine (1) fitness for Federal employment, (2) clearance to perform contractual service for che Federal Government, (3) security clearance or access. The information obtained may be furnished to third parties as necessary in the fulfillment of official responsibilities. Effects of Non-disclosures: Furnishing the requested information is voluntary, but failure to provide all or of part the information may result in lack of further consideration for employment, clearance or access, or in the termination of your employment. [This form may be repllcaced via WP)
Standard Form 85P Revised September 1995 U.S. Office of Personnel Management 5 CFR Parts 731.732, and 736 Form approved: OMB NO. 3206-0191 NSN 7540-01-317-7372 851602 UNTED STATES OF AMERCA AUTHORZATON FOR RELEASE OF MEDCAL NFORMATON Carefully read this authorization to release information about you, then sign and date it in black ink. nstructions for Completing this Release This is a release for the investigator to ask your health practitioner(s) the three questions below concerning your mental health consultations. Your signature will allow the practitioner(s) to answer only these questions. am seeking assignment to or retention in a position of public trust with the Federal Government as a(n) (nvestigator instructed to write in position title.) As part of the investigative process, hereby authorize the investigator, special agent, or duly accredited representative of the authorized Federal agency conducting my background investigation, to obtain the following information relating to my mental health consultations: Does the person under investigation have a condition or treatment that could impair hislher judgment or reliability? f so, please describe the nature of the condition and the extent and duration of the impairment or treatment. What is the prognosis? understand that the information released pursuant to this release is for use by the Federal Government only for purposes provided in the Standard Form 85P and that it may be redisclosed by the Government only as authorized by law. Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for 1 year from the date signed or upon termination of my affiliation with the Federal Government, whichever is sooner. Signature (S~gn in ink) Full Name (Type or Print Legibly) Date Signed Other Names Used Social Security Number Current Address (Street, City) State ZP Code Home Telephone Number (nclude Area Code) ( 1
~ - CHAPLANCY CANDDATE SUPPLEMENTAL NFORMATON FORM U.S. DEPARTMENT OF JUSTCE FEDERAL BUREAU OF PRSONS Date 1. PERSONAL PROFLE 1 Address Telephone: Religious Affiliation: 2. Please provide us with your address (es) for the last five years Address: ( Dates Resided: Address: Dates Resided: Address : Dates Resided: 3. RELGOUS ENDORSEMENT (Religious Certifying Authority, such as Bishop, Superintendent, President, Religious Superior, National Endorsing Agent, etc.) Name Title Address Telephone Religious Affiliation Length of relationship with religious endorsing body 4. EDUCATON College Degree/ Date Address Seminary/Graduate School Degree/Date Address other Graduate Degree (s) Degree/ Date Address - Ordination/Equivalent: ; Yes 1 j No Date Faith Group 5. LANGUAGE SKLLS Are you multilingual:, ' Yes 1 No f yes, list language(s)
6. PROFESSONAL MEMBERSHP (List the Professional, Civic and Religious Organization in which vou hold membership) 7. PERSONAL REFERENCES ( Names and addresses of three persons who can attest to your personal integrity and professional competence.) a. 8. NARRATVE NFORMATON (Provide a thorouqh narrative of the following areas. Please respond in detail as the answers are weighed heavily in the final decision for employment interviews.) a. A biographical summary with specifics about your reason for entering the ministry. b. How did you become interested in the Correctional Chaplaincy? c. what is your concept of pastoral care and how do you perceive its application within the correctional setting? d. How do you sustain yourself spiritually? e. What is the depth of your knowledge of other religious/faith groups and what are your Feelings about assisting other in the practice of their religious beliefs?.. f. A statement of your religious beliefs, practices and doctrine as it relates to violence, terrorism and discrimination. Cite religious doctrine and sacred text references in the formulation of your response. NOTE: A courtesy copy of this application and attachments should be sent to your ecclesiastical endorsing or certifying agent. (This from may be repllcaced vid WP) This form replaces BP-A677 and BP-A678 dtd OCT 04 BP-A0678.039
BP-A0679.039 RELGOUS ENDORSEMENT FOR CHAPLANCY CDFRM MAY 07 U.S. DEPARTMENT OF JUSTCE FEDERAL BUREAU OF PRSONS To: Religious Services Branch Federal Bureau of Prisons, Room 516 320 First Street N.W. Washington, D.C. 20534 Date: - -. - - Applicant nformation Ndme Telephone ENDORSEMENT is defined as "an affirmation by a denomination, religious body or faith group that a person is or will be performing a valid ministry consistent with the faith community granting endorsement and has presented evidence of having the special education, experience and skills necessary to perform that ministry in a correctional setting." hereby assert that this endorsing agency does not espouse racial separatism, domestic and/or foreign terrorism, or advocate violence of any type. hereby certify that the above named applicant: 1. s a fully qualified member in good standing of the clergy of... ~. ~- (Religious Ordaining Body). 2. To the best of my knowledge there is no legal, moral, or ecclesiastical barrier to congregational ministry. nitial: - - 3. Has held an official, ecclesiastical relationship with this endorsing body for a minimum of two years. List years:. -. -. --- nitial : -..- 4. s qualified, in the judgement of this religious body, to represent it in this specialized ministry. nitial: 5. s mature enough in his/her own faith to minister to persons of all faiths (including coordination of programs and supervision of inmate groups) without compromising or projecting personal beliefs. nitial: - -- - 6. s fully eligible and available for a pastoral appointment within the endorsing falth group. nitial: -- 7. s authorized by the endorsing body for secular work and ministry on the weekly day of religious observance and traditional holy days. nitial: The candidate possesses specific ministerial gifts which are suited for correctional ministry (Please comment in narrative form on reverse side)..., therefore, endorse him/her for employment in the Federal Bureau of Prisons as a full time chaplain. Endorser Signature Endorsing Agency 'Typed Name Address Daytime Phone (This from may be replicared via NP This form replaces BP-5679 dtd OCT 01
. BP-~0680. MAY C7 039 CHAPLANCY CANDDATE CERTFCATON AND AUTHORZATON CDFM U.S. DEPARTMENT OF JUSTCE FEDERAL BUREAU OF PRSONS understand and agree to the following conditions of employment in the event that am offered a staff chaplain position in the Bureau of Prisons (BOP). These conditions of employment apply throughout my tenure in the BOP. The inmates comprise my primary congregation; therefore, during my tenure as a BOP chaplain will ordinarily be required to work on the seasonal holy days of my faith tradition. nitial - w i l l be responsible for accommodation of the weekly worship service of my religious tradition. nitial -- - will be required to work two evenings a week. nitial will be required to minister to persons of religious traditions that are at grave variance with my own. nitial will never be required to perform sacraments/rituals or provide worship services outside of my own faith tradition (slamic, Jewish, Protestant, Roman Catholic, etc.) but may be asked to participate in ecumenical or inter-faith services at appropriate times. nitial My role as chaplain does not authorize me to perform sacraments/rituals outside of my own faith tradition (slamic, Jewish, Protestant, Roman Catholic, etc.) even in the absence of a chaplain, contractor or volunteer of that faith tradition. nitial -~ will be required to adhere to the Bureau of Prisons Employee Standards of Conduct. nitial.. ~ Non-compliance with these conditions of employment will routinely result in dialogue between the Chaplaincy Administrator and my endorser. nitial do not espouse racial separatism, domestic/foreign terrorism, or advocate violence of any type. nitial - For BOP Status Employees Only a. Because this chaplaincy position is in the excepted service, understand that the position is not filled by competitive appointment. b. am leaving the competitive service voluntarily to accept the appointment as a chaplain in the excepted service. nitial....... Printed Name: Date : Signature: Witness : (This form may be replicated via WP) This form replaces BP-A680 dtd OCT 03
CREDT RELEASE AUTHOR1 ZATON ATTACHMENT E (PS 3000.2) U. S. DEPARTMENT OF JUSTCE FEDERAL BUREAU OF PRSONS DSCLOSURE AND AUTHORZATON PERTANNG TO CONSUMER REPORTS PURSUANT TO THE FAR CREDT REPORTNG ACT This is a release for the Federal Bureau of Prisons to obtain one or more consumer/credit reports about you in connection with your application for employment or in the course of your employment with the Bureau of Prisons. One or more reports about you may be obtained for employment purposes, including evaluating your fitness for employment, promotion, reassignment, retention, or access to classified information. 1,, hereby authorize the Federal Bureau of Prisons to obtain such report(s1 from any consumer/credit reporting agency for employment purposes. Name (Print or Type) Date Social Security Number 'Credit reports may be utilized for consideration in promotions or reassignment actions to those positions at the Special Sensitive level as defined in Program Statement 3000.2, Attachment 7-3. "Sensitive Limited Official Use Only"