Application: Request to Continue Previously Approved Voluntary Leave of Absence (VLOA) Status
Name: First Middle Last Address: Street City State Zip
Best Contact # (______)________-__________ Birthdate: _________ _________ __________ [__] Cell [__] Home [__] Work Month Day Year
Email:
Clergy Status: [__] Full Elder [__] Full Deacon [__] Provisional Member [__] Associate Member District: [__] AP [__] CM [__] NR [__] SS [__] SM [__] TV
Charge:
Having been previously approved, I would like to request that I remain on: [__] Personal LOA [__] Family LOA
Date original VLOA became effective: _________ _________ __________ Month Day Year
Please note: Failure to request annual extension via submission of this Application may invoke the Action of the 2020/2024 Book of Discipline ¶354.12 and result in your being placed on administrative location (¶360).
(Please remember that this request should be submitted by January 1st of each calendar year.)
Signature Printed Name Date
Office Use:
Date BOMEC/BOM approved request: _________ _________ __________ Month Day Year
Annual Conference Clergy Session __________ [__] did / [__] did not approve this request. AC Year
Please submit to: [__] Chair, Board of Ordained Ministry [__] The Office of the Bishop [__] The Office of Clergy Services via ClergyServices@holston.org [__] DCOM