ST. LOUIS CLUSTER, ACPE
Application For Clinical Pastoral Education

All applicants for all programs must submit a completed application along with the required documentation and fee. Please see item #1 on the “Required Documentation & Instructions” page for mailing instructions.

PROGRAM INFORMATION

Program Preference:

Preferred Program Location:

Earliest Start Date:

* The admission process for the resident program requires an in-person interview.

DIRECTORY INFORMATION

	Last Name:	First Name:
Mailing Address:
City:		State:		Zip:
Country:
	Day Phone:	Other Phone:
E-Mail:		Fax:
		U.S. Citizen:	Yes No

Permanent Address:
City:		State:		Zip:
Country:		Alt E-Mail:

Denomination/Faith Group Affiliation:
Jurisdiction/District/Diocese/Conference/Association:
Jurisdictional Authority (Name/Title):
Local Church & Ministry Position:
Ordained: Licensed: Appointed:		Date:

EDUCATION

		Degree	Date
College:
Seminary:
Grad School:
	Prior CPE Dates	Center	Supervisor

REFERENCES

Academic:

Name/Title:

Address:

City, State and Zip:

Phone Number: Other Number:

E-Mail:

Denominational:

Name/Title:

Address:

City, State and Zip:

Phone Number: Other Number:

E-Mail:

Personal:

Name/Relationship:

Address:

City, State and Zip:

Phone Number: Other Number:

E-Mail:

Admissions Interviewer:

Name:

Address:

City, State and Zip:

Phone Number: Other Number:

E-Mail:

* It is important to provide as much information as possible for each reference. Letters of reference are required for acceptance into ALL Cluster programs.

REQUIRED DOCUMENTATION

A "Required Documentation & Instructions" page will print along with your completed application when you select the "Print This Form" option below. Please be sure to submit ALL the required items with your completed application and fee to avoid any delays in processing.