CANDIDATE NOMINATION PACKAGE (CNP)

Information provided below will assist our team in determining and expediting the essential priorities of effort for your personal success.

SECTION I

Personal Information

Name: *

Age: *

Current Address: *

Phone: *

E-mail address: *

SECTION II

Family Information

Marital Status: *

Spouse Name: *

Children/Gender/Age:

SECTION III

Military Service

Military Status: *
Active DutyReserve DutyVeteranGuard Duty

Military Branch: *
ArmyAir ForceNavyMarine CorpCoast Guard

Current or EAS Rank: *

Military Job Description: *

Current or last military station:

Military Operations Involved In: *
OIFOEFDesert StormOtherNone

Military Service Photo (attachment required): *

Upload DD-214 (photocopy attachment required): *

Discharge Certificate from the U.S. Military (photocopy attachment required): *

SECTION IV

Support System Information

Primary Support Member Name (other than spouse): *

Primary Support Member's Phone Number:

Primary Support Member's E-mail address: *

SECTION V

Reason(s) for applying to participate in The Surrender Project *

Personal Goals (include both current and long term) *

SECTION VI

Healthcare Information (if applicable)

Primary Physician Contact Information:

List any chronic physical injuries or impairments:

Psychologist/Therapist Contact Information:

List any current conditions or past diagnosis:

List all current medications:

SECTION VII

Privacy/Release Statement

I, , do hereby attest that the information provided is true and accurate to the best of my knowledge. I also understand that the submission of this nomination package in no way guarantees my acceptance into The Surrender Project. The Nomination Committee determines acceptance after a thorough review of each nomination package.

I, , do hereby release the above information to be used by SOF Missions and The Surrender Project Nomination Committee for the purpose of determining eligibility for The Surrender Project. if accepted into the Surrender Project, hereby consent to the use of to Shield of Faith Missions Inc. and/or their agents, affiliates, or authorized representatives of photographs or videos in which I appear, and I acknowledge and agree that I have no ownership rights in or to those photographs or videos. I hereby release Shield of Faith Missions Inc. and/or their agents, affiliates, authorized representatives and assigns from any claims that I may have relating to any photographs or videos, including without limitation, any claim arising under the right of publicity, the right of privacy, defamation and/or copyright infringement. I am aware that SOF Missions will share my information with the other Surrender Project partnering organizations.

By checking this box I agree to the terms and conditions above.

Signature: *

Date: *

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