Certification Appendix 9 Attestation of Good Standing Form

Certification Appendix 8:
Attestation of Good Standing Form

For each new committee review in the certification process, an updated Appendix 8 must be submitted.

In preparation for a Readiness Consultation, documentation of the following formal requirements must be submitted for the Appendix 8 to be signed by a national office representative:• Supervisory Education Center letter of good standing, • Current ACPE Clinical membership, and • Ethics section at bottom of this form updated In preparation for review for certification as a Supervisory Candidate, documentation of the following formal requirements must be submitted for the Appendix 8 to be signed by a national office representative: • Supervisory Education Center letter of good standing, • Current ACPE clinical membership, • College graduation and graduate theological degrees (or equivalent), • Ordination or commission to function in ministry by an appropriate religious authority, and • Faith group endorsement/accountability (or equivalent).

In preparation for review for certification as Associate Supervisor, and for Extensions of Supervisory Candidate and Associate Supervisor status documentation of the following formal requirements must be submitted for the Appendix 8 to be signed by a national office representative:• Supervisory Education Center letter of good standing. No other documentation is required unless there are changes.

In preparation for a Competency Review as a CPE Supervisor no other documentation is required except the submission of this Appendix 8 form, to be signed by a national office representative. Submit this form and required documentation to certification@acpe.edu.

ACPE expects those in the certification process and thereafter as Supervisors, to report any changes that impact meeting any of these requirements.

Name of Applicant:

First NameLast Name

Name of Supervisor (if applicable)

First NameLast Name

Letter of Good Standing in current ACPE Sup. Ed program from current ACPE Sup. sent to ACPE:

YesNoN/A

Current ACPE level of membership:

Clinical MemberSup. CandidateAssoc. Sup.CPE Sup.

Expiration Date of Supervisory Candidate/Associate Supervisor Status:

*Current faith group ordination/commissioning by:

*Current faith group endorsement for Sup. Ed. by:

*Faith Group Endorser Name and Contact Information:

Accountability for Ethical Conduct Policy Reporting Form (Appendix 1, Cert. Manual):This form should be submitted when applying for clinical membership.

Is there anything required by the form to report since the form was submitted?

YesNo

If yes, please explain:

If the information provided on this Attestation of Good Standing form is validated, the form will be signed and returned to the student/supervisor. If not, the national office representative will work with the student/supervisor to comply.

I attest that this applicant/supervisor is in good standing with ACPE and his/her Supervisory Education Center (if applicable), and faith group.

Signature of National Office Representative Date: