Question	Answer
Form Name	Missionary Recommendation Checklist
Form Length	21 pages
Fillable?	Yes
Fillable fields	217
Avg. time to fill out	24 min 19 sec
Other names	missionary form template, missionary recommendation form, lds missionary application form, lds mission application form

Full legal name (first)	(middle)	(last)	(suffix)		Date available to
					serve

Home street address

City			State or province	Postal code

Country			District (if any)		Airport

Home phone (include area code)			E-mail address (optional)

Confirmation date		Current marital status				Have you ever been
			Single		Married	Widowed	Divorced

Have ever been arrested (If yes to any of these, explain, including date of arrest, charge, and resolution.)
Yes	No

Have ever had a police record
Yes	No

Have ever been convicted of a crime
Yes	No

Citizenship Information

Citizenship at birth				Place of birth (city, state, or			Birth	Current country of citizenship			If dual citizenship, indicate second
				province)			country				country of citizenship.

You have an official birth certificate				Currently a documented citizen of your resident country (If no, indicate your current status in your country of residence.)
Yes	No			Yes	No

Citizenship status imposes restrictions on traveling outside				Nationalities of ancestors
the country where you live
Yes	No

You have a current passport				Expiration date:					Name (exactly as it appears on the passport)
Yes	No

Passport Number				Country of Issue

Father's Information

Father's full name				Father is a member					Father is deceased
				Yes	No				Yes	No

Father's birthplace (city, state, or province)				Father's occupation

Father's street address, if different from your home address

City				State or province					Postal code

Country				District (if any)

Mother's full name					Mother is a member		Mother is deceased
					Yes	No	Yes	No

Mother's birthplace (city, state, or province)					Mother's occupation

Mother's street address, if different from your home address

City					State or province		Postal code

Country					District (if any)

Home phone (include area code)					E-mail address (optional)		Check here if you do NOT want your mother to be
							contacted at all.

Residence and Caregiver Information

You live with:
Both parents		Mother only	Father only	Other (name)			(relationship)
Both parents		Mother only	Father only	Other (name)

If you do not live with both parents, please explain why.

Address of caregiver, if other than parents and different from home address

City					Postal code		Country

State or province					District (if any)

Home phone (include area code)					E-mail address (optional)		Check here if you do NOT want this person to be
							contacted at all.

Other Family Members Who Have Served or Are Serving Missions

Father has served a mission (If yes, give name of mission.)					Mother has served a mission (If yes, give name of mission.)		Grandparents have served missions (If yes, give name of
Yes	No				Yes	No	missions.)
Yes	No				Yes	No
							Yes	No

Bishop or branch president's signature	Telephone (include area code)	Date submitted

Print name	Unit name	Unit number

Stake or mission president's signature	Telephone (include Area Code)	Date submitted

Print name	Unit name	Unit number

0	1	2	3	4	5	6	7
No English	Nonfunctional		Partially Functional		Functional		Fluent

Level A—No limitation	Level B—Slight limitation	Level C—Moderate limitation	Level D—Marked limitation	Level E—Not appropriate
No limitation of activity in lifting,	Slight limitation of activity; slight	Moderate limitation of activity;	Marked limitation of activity or has	Conditions exist for which corrective
carrying, walking 6 or more	decrease of function or stamina,	moderate decrease of function or	special requirements, such as specific	action has not been or cannot be
miles per day, or spending 12 to	such as problems with walking	stamina; requires limited walking	climate, use of wheelchair, frequent	taken, such as severe chronic pain,
16 hours per day in missionary	(limited to 3-6 miles per day) or with	(0-3 miles per day) or sedentary	rest periods, special medical needs, or	loss of stamina, or recurring
activity.	extensive standing.	work.	medical visits.	conditions.

Selected Limitations

Additional Comments

Office experience
General bookkeeping	Word processing	WPM	Computers	Details

Current or previous military experience		Name of military organization
Yes	No

Member of military reserve unit (U.S. only)		Name of reserve organization
Yes	No

Reserve service number		Name of commanding officer

Low	1	2	3	4	5	High
Low						High

1. Complete all information on the Missionary Recommendation form.		Have the physician complete the Physician's Health Evaluation of
Type if possible, or print neatly in black ink. Write dates in day, month,		Missionary Candidate form and mail it and the Personal Health History
year format (15 Dec 2001).		of Missionary Candidate form to your bishop or branch president.
2. Complete the Education and Service of Missionary Candidate form. Fill		Where mail is unreliable, personally retrieve the forms.

out the Personal Health History of Missionary Candidate form	7.	Begin the hepatitis A and B immunizations and boosters for diphtheria,
completely, honestly, and accurately before your medical examination.		tetanus, measles, and mumps immediately. You will receive additional
3. Sign the “Authorization to Release Information” section on the		immunization information with your mission call.

Physician's Health Evaluation of Missionary Candidate form.	8.	Obtain a thorough dental examination. Begin early. Sign the
4. If you have had any major illness, major operation, major injury,		“Authorization to Release Information” section on the Dental Evaluation
		for Missionary Candidate form, and give the form to the dentist along
prolonged treatment, or hospitalization, obtain a statement from the
		with a stamped envelope addressed to your bishop or branch
professional who treated you, if possible, to explain the nature of the		with a stamped envelope addressed to your bishop or branch
		president. Have the dentist fill out the form and mail it to your bishop or
problem and its current status. It is important that you provide complete
		branch president. Where mail is unreliable, personally retrieve the
information about your physical condition. For example, it is not enough
		forms.
to say that you had a knee injury; you must also state which knee was		forms.

injured and explain whether there are any persistent problems with the	9.	Have all dental work, including orthodontic work, completed before
knee.		submitting the missionary recommendation packet to your bishop or
5. The Physician's Health Evaluation of Missionary Candidate form must		branch president.

be signed by a medical doctor (MD) or doctor of osteopathy (DO). If the	10.	You are expected to be physically and emotionally capable of working
examination is done by a physician assistant (PA) or nurse practitioner		several hours a day. For young missionaries, this means walking
(NP), the supervising physician must verify the findings and review and		several miles a day six days a week. If there are reasons why this
countersign the form. An examination by any other practitioner is not		might not be possible, please discuss them with your bishop or branch
acceptable.		president.
6. Give the following forms to the physician along with a stamped envelope	11.	Before entering the MTC, correct any problems such as plantar warts,
addressed to your bishop or branch president:		flat feet, chronic headaches, inguinal hernias, and so on. Stabilize and
The completed Personal Health History of Missionary Candidate		understand the treatment for chronic problems such as asthma,
		diabetes, seizures, emotional disorders, irritable bowel, endometriosis,
form.
form.		and so on.
The Instructions for Physicians Evaluating Missionary Candidates.		and so on.

The Physician's Health Evaluation of Missionary Candidate form.	12.	If you are taking prescribed medication for any chronic problem,

Home ward or branch		Unit number	Home stake or mission

Name of home bishop or branch president			Name of home stake or mission president

Mailing address (including country)			Mailing address (including country)

Home phone (area code)	Work phone (area code)	Cell phone (area code)	Home phone (area code)	Work phone (area code)	Cell phone (area code)

E-mail address		Fax	E-mail address		Fax

Unit Information for Unit Submitting Recommendation If other than home unit

Ward or branch		Unit number	Stake or mission

Name of bishop or branch president			Name of stake or mission president

Mailing address (including country)			Mailing address (including country)

Home phone (area code)	Work phone (area code)	Cell phone (area code)	Home phone (area code)	Work phone (area code)	Cell phone (area code)

E-mail address		Fax	E-mail address		Fax

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