"*" indicates required fields Section 1: General InformationName* First Last Are you a bishop, priest or deacon?* Priest Deacon Bishop Email* Phone*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is any of the information listed above new?* Yes No Section 2: Exercise of Ordained MinistryWere you serving as a chaplain in 2024?* Yes No If serving as a chaplain, please indicate whereWere you secularly employed in 2024?* Yes No If secularly employed in 2024, please indicate position and employerNOTE: In the MINISTRY SPECIFICS (Section 5), please list all Ecclesiastical Acts performed other than in the congregation to which you were assigned. (EX: Supply work at St. June's, Anytown, MO / Part-time work at St. Bob's, There, MO). With that in mind, please answer: In 2024, I was assigned to a congregation or congregation(s) as part-time or supply clergy and all Ecclesiastical Acts which I performed while assigned there are recorded in those parish registers. I was not assigned to a congregation I was employed in a church-related position i.e. chaplaincy, diocesan staff, mission, etc. (in the MINISTRY SPECIFICS section below, list all Ecclesiastical Acts performed other than those performed in such church-related position) I did not exercise my ordained ministry; I am retired and not functioning liturgically in any way (no need to complete the remainder of this form) I had health issues which prevented me from exercising my ministry (no need to complete the remainder of this form) I did not exercise my ordained ministry for other reasons; please explain in "other" section below (no need to complete the remainder of this form) Section 2.2 - If you selected option one above, notes may be added here, but Section 5 is required. (otherwise, please disregard).Section 3: Summary of Ordained MinistryPlease enter only those acts which were not listed above.Indicate the number of Eucharists celebrated in 2024*Indicate the number of Eucharists assisted in 2024*Indicate the number of Morning/Evening Prayer services performed in 2024*Indicate the number of sermons delivered in 2024Indicate the number of baptisms delivered in 2024*Indicate the number of marriages performed in 2024*Indicate the number of burials performed in 2024*Indicate the number of hospital visits in 2024Indicate the number of persons presented for Confirmation in 2024Indicate the number of pastoral visits in 2024Indicate the number of counseling sessions in 2024Indicate the number of lectures in 2024Section 4: Ministry SpecificsProvide specifics: Ecclesiastical Act, Church, City/State, Month/Year for Eucharists, prayer services, baptisms, marriages, burials performed.Section 5: Non-Canonically Resident Clergy ONLYI am canonically resident in the diocese of:As a non-canonically resident clergy person, I wish to be relicensed to officiate in the Diocese of West Missouri for the year 2025 (NOTE: failure to complete this request will result in license expiration). Yes No EmailThis field is for validation purposes and should be left unchanged.
