Attachment 2) BP_A0778 - Credentials of Religious Services Contractor.pdf

BP-A0778 U.S. DEPARTMENT OF JUSTICE

JUN 10 FEDERAL BUREAU OF PRISONS

CREDENTIALS OF RELIGIOUS SERVICES CONTRACTOR

1. PERSONAL PROFILE

Name Address

Telephone Religious Affiliation

Civic Affiliations Professional Affiliations

Country of Origin Citizenship

Immigration Number (If Landed Immigrant)

Naturalization Number (If Naturalized Citizen)

Foreign Travel (Countries Visited Last Five Years And Time Frames)

Funding from Foreign Governments

Have you lived in the United States three of the last five years? ____ Yes ____ No

2. VERIFIABLE RELIGIOUS CREDENTIALING AUTHORITY (Religious Certifying Authority, such as Superintendent, President, Religious Superior, Pastor, etc.)

Name Title

Address Telephone

Local Congregation (Name and Address) Length of relationship with religious credentialing authority

3. EDUCATION

College Degree/Date

Seminary/Graduate School Degree/Date

Other Graduate Degree(s) Degree/Date

4. As a religious service contractor, I am aware of and agree to comply with Code of Federal Regulations Rule §548.15, which states, “no one may disparage the religious beliefs of an inmate, nor coerce or harass an inmate to change religious affiliation. Attendance at all religious activities is voluntary and unless otherwise specifically determined by the warden, open to all.” I do not endorse nor will I practice or use language in the institution that will support violence, terrorism, discriminate against other inmates or exclude other inmates from religious services based on race, color, religion, gender, or national origin.

Signature of Contractor: Date:

PDF Prescribed by P5360 This form replaces BP-S778.053 dtd OCT 04

The Following Section to be Completed by the Religious Services Program Manager

Ordination/Equivalent:

Yes: ____ No: ____

Faith Group Date

Comments:

Interview Summary Comments (If Needed) Interview Date:

Program Manager’s Signature Date

Religious Subject Matter Expert (SME)Review (If Needed)

Comments

Religious SME Recommends Contractor _____ Religious SME does not Recommend Contractor _____

Date Reviewed: Signature of Religious SME:

Chaplain Review:

I have reviewed the personal information presented by the prospective religious vendor.

I recommend this vendor for consideration of award of contract.

I do not recommend this vendor for consideration of award of contract.

Chaplain Signature Date

Attach Supporting Documentation (e.g., copy of Immigration or Naturalization Number) cc: Contracting Office Contractor Security File

PDF Prescribed by P5360 This form replaces BP-S778.053 dtd OCT 04