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Fillable Printable VA Form 10-0379

Fillable Printable VA Form 10-0379

VA Form 10-0379

VA Form 10-0379

10-0379
VA FORM
DEC 2005
Page 1 of 3
ECCLESIASTICAL ENDORSING ORGANIZATION
REQUEST TO DESIGNATE ECCLESIASTICAL ENDORSING OFFICIAL
OMB Number 2900-0610
Estimated Burden 45 min.
PAPERWORK REDUCTION ACT: This information is used by VA to show that religious faith groups meet
reqirements 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
(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
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
10-0379
VA FORM
DEC 2005
Page 2 of 3
ECCLESIASTICAL ENDORSING ORGANIZATION
REQUEST TO DESIGNATE ECCLESIASTICAL ENDORSING OFFICIAL (Con't)
7. E-MAIL ADDRESS (If applicable)6. INTERNET SITE 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)
b. TITLEa. NAME (Last, First, Middle Initial)
f. ZIP CODE
e. STATE
d. CITYc. STREET (Include apartment or suite number)
h. FAX NUMBER (Include area code)g. TELEPHONE NUMBER (Include area code)
j. E-MAIL ADDRESS (If applicable)i. INTERNET SITE ADDRESS (If applicable)
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)
10. IS YOUR ORGANIZATION/RELIGIOUS BODY PRIMARILY ORGANIZED TO PROVIDE RELIGIOUS
MINISTRIES TO A LAY CONSTITUENCY? YESNO
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?
NOYES
11a. IF NO, EXPLAIN
AL
AL
10-0379
VA FORM
DEC 2005
Page 3 of 3
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?
12. DOES YOUR ORGANIZATION/RELIGIOUS BODY PRESENTLY HAVE AN AGENT AUTHORIZED TO
GRANT AND WITHDRAW ECCLESIASTICAL ENDORSEMENTS TO THE MILITARY?
ECCLESIASTICAL ENDORSING ORGANIZATION
REQUEST TO DESIGNATE ECCLESIASTICAL ENDORSING OFFICIAL (Con't)
NOYES
12a. IF YES, GIVE THE NAME AND PHONE NUMBER OF THE AUTHORIZED AGENT
NOYES
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
A. CHURCHES
NUMBER OF CLERGY
16. TOTAL NUMBER OF: (SELECT THE CATEGORY THAT MOST CLOSELY FITS YOUR ORGANIZATION)
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)
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