MISSION PERSONNEL INFORMATION

Basic Data

Last Name

First

Middle Initial

Social Security #

Address

Home Telephone

City

State

Zip

Work or School Telephone

E-Mail

Alternate address of a person who can always reach you:
Name	Relation
Address
City/State/Zip
Telephone

Are you a US Citizen?

Yes
No

If no, do you have the legal right to retain employment in the US?

Yes
No

Date of Birth

Place of Birth

What is your primary language?

What other languages do you speak? Levels: T = Tourist; C = Conversational; NF = Nearly Fluent

Availability and Program

Desired length of service ( ✓✓ double check first preference; ✓ single check all other possibilities)

more than 4 years	2 years	3-6 months
2-4 years	6-12 months	less than 3 months
summer service only

Date available for service:

Keep application open until this date:

What issues/factors could affect:

a) your availability:

b) your ability to complete the intended period of service?

Program preference (refer to descriptions in cover letter)

✓✓Double check first preference

✓ Single check all other possibilities

Long-term mission personnel

Volunteer for Mission (1-year program)

Episcopal Young Adults Service

Assignment-Check appropriate boxes

Open to discuss a variety of position/program options

Particular interest in the following positions/programs

Open to serving in a variety of geographical settings

Particular interest in the following geographical regions:

TYPES OF MISSION SERVICE for which you believe you can do well in an international context:
(check all that apply):

Administration/Professional: specify field:

Community Development/Agriculture: specify field

Education: English as Second Language

Education (K-12): preferred subject/grade level:

Education (post-secondary/graduate/theology): subject areas & level:

Education (other): specify field:

Evangelism: special interest area

Health Care: field/specialization

Support Services (bldg & maint., skilled trade, child care, office etc.): specify field

Youth or Social Service: specify field

Other: specify

Church Membership
Parish: Diocese: Church in Communion with the Episcopal Church:

Address

City/State/Zip

Denomination

Priest/Pastor:

Telephone

Describe your involvement in congregation/church:

Volunteer Service

Describe your involvement in civil or volunteer service:

Education
SCHOOL NAME AND LOCATION	Course or Major	No. of Years	Degree and Date
High School
College or University
Graduate School/Seminary
Business/Trade/Technical/or Other Schools
Other Continuing Education
Honors or Awards

Employment History
Begin with current or most recent employer. Include those posiions for which you worked more than 20 hours per week.
1. Employer Name	Position Title
Address City/State/Zip Telephone	Date employed: from/to Description of responsibilities
May we contact your current or most recent employer at this time? Yes No	Date employed: from/to Description of responsibilities
2. Employer Name	Position Title
Address City/State/Zip Telephone	Date Employed: from/to Description of responsibilities
3. Employer Name	Position Title
Address City/State/Zip Telephone	Date employed: from/to Description of responsibilities

Occupation and Skills
Occupation (if student, intended occupation)
Principal job-related skills you possess that may be used in an international context
Other skills or abilities (P= Professional Training; E= Experienced; H= Hobby/nontechnical ability)
Job-related Licenses or Certificates/ State or Licensing Agency / Expiration Date

Marital Status
Single never married	Separated - date of separation
Engaged - date of wedding:	Previously married - date of dissolution
Married - date of marriage	Widowed
Full Name of spouse	Citizenship of spouse
If you are married, does your spouse plan to accompany you? Yes No Couples Please Note: Each adult intending to live in the assigned country needs to fill out a separate Mission Personnel Information form, whether or not he/she seeks a mission assignment.

Family
Provide information about your dependents. Place a "✓" by those who will accompany you to the country of service.
✓	Full Name	Date of Birth	Citizenship

Placement and Match-making

Placement may be influenced by such factors as finances, housing, educational needs of children or other family or personal issues

Financial considerations: Do you have particular financial considerations that might influence the type and
length of assignment you could accept?

Yes
No

(If yes, please explain)

Life situations: Service in international settings may present challenges related to health, environment,
climate and security among others. These issues may affect a person's ability to live and work in a
particular setting.
Indicate below any concerns you have related to the following:

Diet
Environment
Availability of medical care/medications
Exercise
Climate
Security
Other-specify

Describe:

Children's education (if applicable): If you have or expect to have school age children your term of service,
are you open to: (check all that apply)

Local schools (non-English)	Boarding school in English language school
Local schools (English language)	Home School

Comments:

Passport Information
A passport is necessary for international service. If you currently have a passport, indicate below:
Full Name	Passport No.	Country of Issue	Expiration Date

Legal consideration
Sexual Misconduct Policy Certification: (a) Has any civil, criminal, or ecclesiastical complaint ever been sustained or brought against you for sexual misconduct? Yes No (If yes, attach statement) (b) Have you ever resigned or been terminated from a position for reasons related to sexual misconduct? Yes No (If yes, attach statement)
Prior or Pending Offenses: (a) Have you ever been convicted of, pled guilty to or pleaded "no contest" to any crime, other than minor Traffic violations? Yes No (If yes, attach statement) (b) Are any charges (for any offense, including traffic offenses), civil suits, or judgments outstanding against you? Yes No (If yes, attach statement)

References
Provide four names, including, pastor, professional/academic, employer
Print names and information neatly and clearly
1. Name	2. Name
Occupation	Occupation
Telephone Number	Telephone Number
Email	Email
Address	Address
3. Name	4. Name
Occupation	Occupation
Telephone Number	Telephone Number
Email	Email
Address	Address

Additional Information
How did you learn about global mission opportunities with the Episcopal Church? Check all that apply.
Clergy Friend/family Printed materials/announcement at church Mission event Contact with staff person	College career service office College professor Surfing the web Advertisement Other: specify

EPISCOPAL CLERGY AND OTHER ROSTERED PERSONS

NOTE: You need to notify your bishop that you are in conversation with Mission Personnel.
Check here if you have notified your bishop Name of Diocese	Date of Ordination

PLEASE READ CARE FULLY BEFORE SIGNING
1.	All information provided on this Mission Personnel information form is complete and accurate, to the best of my knowledge.
2.	Candidates who serve with the Episcopal Church Mission Personnel Office will be expected to understand, respect, and support the mission of the Episcopal Church Center.
3.	Misrepresentation of facts in this Mission Personnel Information form will disqualify me from further consideration or, if! serve with the Episcopal Church Mission Personnel Office, may be sufficient cause for dismissal.
4.	In compliance with Federal laws, all offers of employment are subject to verification of each applicant's identity and employment authorization. I understand that it will be necessary for me to submit such documents as are required by law to verify my identification and employment authorization.
5.	Any position offered to me is contingent upon the satisfactory completion of reference checks and any other checks, testing or examinations as may be requested by the Episcopal ChurchlMission Personnel Office.
6.	I understand that nothing contained in this form, or in the granting of an interview is intended to create a contract between the Episcopal ChurchlMission Personnel and me, either for employment or for providing of any benefits. No promises regarding employment have been made to me, and I understand that no such promises or guarantee is binding upon the Episcopal ChurchlMission Personnel unless made in writing.
7.	The Episcopal ChurchlMission Personnel has my permission to investigate, at its discretion, my past employment history, personal references, and any other information contained in this Mission Personnel Information form.
8.	I fully agree to the statements and conditions listed 1 through 7 above.
	Applicant's Signature	Date

Use the checklist below to ensure your Mission Personnel Information form package is complete:

Complete and sign the Mission Personnel Information form

Spouse provides a separate Mission Personnel Information form (if applicable)

Reference information printed neatly and clearly

Include your name on the top of each page of your responses to the Narrative Section

Send completed Mission Personnel Information
form, narrative and resume to:
Mission Personnel, 6FL
The Episcopal Church Center
815 Second Ave
New York NY 10017-4561

Questions related to completing the Mission Personne
Information form can be directed to staff at
Mission Personnel:

Phone:	1-800-334-7626 ext. 6124
Fax:	212-983-6377
E-Mail:	mjobson@episcopalchurch.org

MISSION PERSONNEL INFORMATION Narrative Section

Write your responses below. Try to find that fine line between writing too much (1/2 page per question) and too little (one or two sentences per question). The total of your responses should not be more than two or three typed pages.

Tell us a little bit about yourself.
Use these guidelines if you choose:
- Qualities you have... Qualities you don't have
- What are you good at? Not so good at?
- Situations you are comfortable in... Situations you should stay away from
Describe your Christian faith and how you see God is active in your life.
What excites or intrigues you about global mission service?
What do you anticipate to be most difficult or challenging for you?
Describe any cross-cultural experiences you have had. What did you learn about your abi~ity
to live and work in a cross-cultural context. (If you have had limited cross-cultural
experience, describe how you see yourself living and working in a cross-cultural context).
What other information or considerations to your candidacy do you wish to communicate?

Verify You Are Human
What number comes after 99?

MISSION PERSONNEL INFORMATION

Basic Data

Availability and Program

Volunteer Service

Begin with current or most recent employer. Include those posiions for which you worked more than 20 hours per week.

Provide information about your dependents. Place a "✓" by those who will accompany you to the country of service.

Placement and Match-making

Placement may be influenced by such factors as finances, housing, educational needs of children or other family or personal issues

A passport is necessary for international service. If you currently have a passport, indicate below:

Provide four names, including, pastor, professional/academic, employer Print names and information neatly and clearly

NOTE: You need to notify your bishop that you are in conversation with Mission Personnel.

Narrative Section

Provide four names, including, pastor, professional/academic, employer
Print names and information neatly and clearly