Form 16

________________________________________________________________

Certificate of Ministerial Credentials In the Reformed Presbyterian Church of North America

________________________________________________________________ Name: (Last Name) (First Name) (Second Name)

________________________________________________________________

Birthplace: Date of Birth: _________________________

Citizenship: ___________________________ ________________________________________________________________

Baptized on __________________ day of _____________________ in the year ________________ in the ________________________________ congregation.

Profession of Faith on the __________________ day of ________________ in the year _________________ in the _____________________________________ congregation.

Education

Institutions attended (High School +) From to Diploma/Degree

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Record of Service

________________________________________________________________

Date Presbytery

1. Taken under care as a student of theology

________________________________________________________________

2. Certificate to Preach

________________________________________________________________

3. Certificate of Licensure

________________________________________________________________

4. Ordination

________________________________________________________________

5. Other service in the church and other denomination(s)

Installed in ___________________________ congregation

Released from ________________________ congregation

________________________________________________________________

Installed in ___________________________ congregation

Released from ________________________ congregation

________________________________________________________________

Installed in __________________________ Board/Presbytery Released from _________________________ Board/Presbytery Installed in __________________________ Board/Presbytery Released from ________________________ Board/Presbytery

Other: (Disciplinary actions, restorations, etc.)

________________________________________________________________

________________________________________________________________

________________________________________________________________