ST. LOUIS CLUSTER, ACPE
Application For Clinical Pastoral Education

* New pricing effective September 1, 2009. See "Cluster Programs and Application Process" for more information.

PROGRAM INFORMATION

Program Preference:

Preferred Program Location:

Earliest Start Date:

* The admission process for the resident program requires an in-person interview.

DIRECTORY INFORMATION

	Last Name:	First Name:
Social Security Number:
Mailing Address:
City:		State:	Zip:
Country:
	Home Phone:	Work Phone:
E-Mail:		Fax:

Permanent Address:
City:		State:	Zip:
Country:		Alt E-Mail:

Denomination/Faith Group Affiliation:
Jurisdiction: District: Diocese: Conference: Association:
Jurisdictional Authority (Name/Title):
Local Church & Ministry Position:
Ordained: Licensed: Appointed:		Date:

EDUCATION

	Degree	Date
College:
Seminary:
Grad School:
Prior CPE Dates:

REFERENCES

Academic:

Name/Title:

Address:

City, State and Zip:

Phone Number: Other Number:

E-Mail:

Denomination:

Name/Title:

Address:

City, State and Zip:

Phone Number: Other Number:

E-Mail:

Personal:

Name/Relationship:

Address:

City, State and Zip:

Phone Number: Other Number:

E-Mail:

* It is important to provide as much information as possible for each reference. Letters of reference are required for acceptance into ALL Cluster programs and must be forwarded with your application.

REQUIRED DOCUMENTATION

A "Required Documentation & Instructions" page will print along with your completed application when you select the "Print This Form" option below. Please be sure to submit ALL the required items with your completed application and fee to avoid any delays in processing.