Form 10-0379 ECCLESIASTICAL ENDORSING ORGANIZATION

OMB Number 2900-XXXX Estimated Burden 45 min. Expiration Date: XX/XX/XXXX
	ECCLESIASTICAL ENDORSING ORGANIZATION REQUEST TO DESIGNATE ECCLESIASTICAL ENDORSING OFFICIAL
PAPERWORK REDUCTION ACT: This information is used by VA to show that religious faith groups meet requirements to endorse individuals for service as VA chaplains. Although response is voluntary, failure to respond may result in delay in accepting ecclesiastical endorsements from the religious faith group. In accordance with the Paperwork Reduction Act we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the average time expended by all individuals who must complete this form will be 45 minutes. This includes time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
INSTRUCTIONS
Religious organizations seeking to endorse individuals for work as VA chaplains must fulfill the following requirements:
(1) Must be organized exclusively or substantially to provide religious ministries to a lay constituency (2) Must have authority to grant and withdraw ecclesiastical endorsements of its members. (3) Must agree to notify VA of the withdrawal of an ecclesiastical endorsement (4) Must be recognized by the Internal Revenue Service as a tax-exempt religious organization under Section 501 (c)(3) of the Internal Revenue Code (5) Endorsed individuals must support the free exercise of religion by all patients, family members, and others authorized to receive VA health care. (6) Must complete and submit this form to the National VA Chaplain Center along with the required documents as listed below
DOCUMENTS THAT MUST ACCOMPANY INITIAL REQUEST
In accordance with Veterans Health Administration policy, the following information is required from religious organizations that request to designate an official to issue and withdraw ecclesiastical endorsements of their members. This information will be updated every three years
(1) Explanation of the structure and purpose of the organization (copies of articles of incorporation, by-laws, constitution, etc) (2) Membership requirements of the organization (3) Requirements for membership in the clergy (education, experience, licensure, ordination etc.) (4) Documentation from the IRS that the organization is exempt from Federal income tax as a religious organization under Section 501(c)(3) of the Internal Revenue Code (5) Name, address, and phone number of each person seeking ecclesiastical endorsement for appointment as a VA chaplain

ECCLESIASTICAL ENDORSING ORGANIZATION REQUEST TO DESIGNATE ECCLESIASTICAL ENDORSING OFFICIAL
1. REQUEST DATE:      	2. NAME OF ORGANIZATION:      
3. ADDRESS
a. STREET (Include apartment or suite number)      		b. CITY      		c. STATE      	d. ZIP CODE      
4. TELEPHONE NUMBER (Include area code)      			5. FAX NUMBER (Include area code)      
6. INTERNET SITE ADDRESS (If applicable)      			7. E-MAIL ADDRESS (If applicable)      
8. PRESIDING OFFICIAL(S)
a. NAME (Last, First, Middle Initial)      			b. TITLE      
9. INDIVIDUAL DESIGNATED TO ISSUE AND WITHDRAW ECCLESIASTICAL ENDORSEMENTS (This cannot be an individual seeking to become a VA chaplain)
a. NAME (Last, First, Middle Initial)      			b. TITLE      
c. STREET (Include apartment or suite number)      		d. CITY      		e. STATE      	f. ZIP CODE      
g. TELEPHONE NUMBER (Include area code)      			h. FAX NUMBER (Include area code)      
i. INTERNET SITE ADDRESS (If applicable)      			j. E-MAIL ADDRESS (If applicable)      
10. IS YOUR ORGANIZATION/RELIGIOUS BODY PRIMARILY ORGANIZED TO PROVIDE RELIGIOUS MINISTRIES TO A LAY CONSTITUENCY? YES NO
11. HAS THE MEMBERSHIP OF YOUR ORGANIZATION/RELIGIOUS BODY AUTHORIZED THE ORGANIZATION/RELIGIOUS BODY AS THEIR SOLE AGENCY FOR THE PURPOSE OF ENDORSING INDIVIDUALS TO SERVE AS VA CHAPLAINS? YES NO
11a. IF NO, EXPLAIN      

ECCLESIASTICAL ENDORSING ORGANIZATION REQUEST TO DESIGNATE ECCLESIASTICAL ENDORSING OFFICIAL
12. DOES YOUR ORGANIZATION/RELIGIOUS BODY PRESENTLY HAVE AN AGENT AUTHORIZED TO GRANT AND WITHDRAW ECCLESIASTICAL ENDORSEMENTS TO THE MILITARY? YES NO
12a. IF YES, GIVE THE NAME AND PHONE NUMBER OF THE AUTHORIZED AGENT      
13. IS YOUR ORGANIZATION/RELIGIOUS BODY PART OF ANY OTHER ORGANIZATION/RELIGIOUS BODY THAT PRESENTLY HAS AN AGENT AUTHORIZED TO GRANT AND/OR WITHDRAW ECCLESIASTICAL ENDORSEMENTS TO EITHER THE MILITARY OR THE DEPARTMENT OF VETERANS AFFAIRS? YES NO
13a. IF YES, GIVE THE NAME OF THE ORGANIZATION/RELIGIOUS BODY AND THE NAME OF THE AUTHORIZED ENDORSING AGENT      
14. TOTAL NUMBER OF CLERGY		     	15. TOTAL MEMBERSHIP OF THE ORGANIZATION/RELIGIOUS BODY		     
16. TOTAL NUMBER OF: (SELECT THE CATEGORY THAT MOST CLOSELY FITS YOUR ORGANIZATION)
A. CHURCHES NUMBER OF CLERGY      	B. PARISHES NUMBER OF CLERGY      		C. CONGREGATIONS CLERGY      	D. LOCAL ASSEMBLIES CLERGY      
BY SIGNING BELOW I ATTEST THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE FOLLOWING (A -G)
A. I am authorized by this organization to designate the endorsing official named in block 9a, to verify that the organization meets the requirements listed in the instructions on the front of this form, and to verify the answers to the questions below.
B. This organization meets the requirements listed in the instructions on the front of this form. If this organization ceases to meet any of these requirements we will immediately notify the director, Chaplain Service of the Department of Veterans Affairs.
C. Acceptance of an ecclesiastical endorsement by VA does not imply any approval by VA of the theology or practices of a religious organization, nor does it obligate VA to employ the endorsed individual or any other members of the organization.
D. VA's mission to provide health care to veterans is always paramount, and VA reserves the right to restrict or prohibit within its facilities any practices that it deems detrimental to the health or safety of patients.
E. Individuals endorsed by the organization shall function in a pluralistic environment and will support directly and indirectly the free exercise of religion by all patients, family members and others authorized to receive VA health care.
F. The documents accompanying this form are complete and accurately describe the organization's beliefs, policies, and practices.
G. The organization, and individuals it endorses, agree to abide by all Federal, VA and VHA laws, regulations, policies and issuances on the qualification, endorsement, selection, and employment of VA chaplains.
17. SIGNATURE OF SENIOR PRESIDING OFFICIAL (LISTED IN ITEM 8)      

VA FORM DATE

10-0379

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