The School of Theology
of the Primitive Methodist Church

Permission Form ~ ~ ~ Application Package (Local Preacher)

Note: Your signature on this form grants the School of Theology permission to check all states for any criminal record charge or conviction.

Print clearly your full name _____________________________________

Print any alias names used:



Social Security Number ______ - _____ - ________
Date of Birth _________________

Are you a citizen of the United States? _____
Place of Birth __________________________



Please list any state you have lived in during the past twenty years (we do not check juvenile records)

State ____________ City ______________________ Dates _____________
State ____________ City ______________________ Dates _____________
State ____________ City ______________________ Dates _____________
State ____________ City ______________________ Dates _____________
State ____________ City ______________________ Dates _____________
State ____________ City ______________________ Dates _____________
State ____________ City ______________________ Dates _____________



Have you ever been convicted or pled guilt of any crime? ________

If so, please give the details:







Is there any information that the faculty of this School of Theology might find pertinent when making a decision on whether or not to recommend you as a candidate for ordination? _________________

If so, please give a brief summary of the details:











Signature: I acknowledge the right of the Primitive Methodist Church in the USA to fully examine and check any pertinent information about those applying for recognition and licensing within their Conference, including previous criminal records. I hereby give permission to the School of Theology of the Primitive Methodist Church in the USA to conduct a criminal background check about myself, in any state in which I have lived during the past twenty years. I hereby confirm that all the information I have recorded on this page is complete and true.



_____________________________________________ ____________
                                          Signature                                     Date


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