APPLICATION QUESTIONNAIRE

 

1. Name: __________________________________

 

2. Are you presently the subject of a Title IV proceeding?     Yes       No

 

3. Are you presently the subject of a Complaint or ecclesiastical investigation?     Yes    No

 

4. If you answered yes to either question 1 or 2, please answer the following:

 

a. Alleged misconduct _______________________________________________________

 

b. Diocese ____________________________

 

c. Status of Proceeding _________________________________

 

d. Are you presently represented by counsel?     Yes    No

 

Name _____________________________________

 

Address__________________________________________________

 

Telephone _______________________

 

Email address_____________________________________________

 

5. Are you presently subject to a Pastoral Direction?    Yes    No

 

If yes, please answer the following:

 

a. Bishop ______________________________

 

b. Date issued __________________________

 

c. Please provide a copy of the Pastoral Direction

 

6. Are you presently on Administrative Leave or other restriction on ministry?   Yes   No

 

If yes, please answer the following:

 

a. Bishop ______________________________

 

b. Date issued _________________________

 

c. Please provide a copy of the notification letter

 

7. Are you subject of an Accord entered under Canon IV.9 or Canon IV.14?   Yes   No

 

If yes, please provide a copy.

 

8. Have you ever been the subject of any Title IV proceeding or any other ecclesiastical discipline?   Yes   No

 

If yes, please answer the following:

 

a. Alleged misconduct/canonical offense ___________________________________________

 

b. Diocese ________________________________

 

c. Resolution _____________________________________________________________

 

d. Date of resolution _______________________

 

e. If the subject of a Voluntary Submission to Discipline under the former Title IV, please attach a copy. 


 

f. If the subject of a Judgment entered by an Ecclesiastical Court, please attach a copy.

 

g. Sentence imposed, if applicable _____________________________________________

 

 


 

 

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