Throne of Grace Ministries – LIFE CENTER

Resident Application

Our Mission

We exist to raise people to a new level of living; spiritually, physically, emotionally and financially by teaching them principals from The Bible which we believe is the inerrant and inspired Word of God.

We Are A Life-Line

This Ministry is your LIFE-LINE, where you receive your “Spiritual Food”.
(Malachi 3:8-10)

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Full Legal Name:

First

Last

Age:

Birth Date:

Social Security Number:

Drivers license or id #:

Make and model of vehicle?

Vehicle Tag #:

Vehicle Color:

Person to contact in emergancy?

Phone Number:

Emergency Contact address:

Contact relation:

Second contact name?

Second contact phone number?

Second contact address?

Second contact relation?

Are you a member of any Church or Christian organization?

WHO REFERRED YOU TO THIS PROGRAM?

Layout

Do you have a valid license to drive?

ALCOHOLIC?

Do you have an automobile?

OTHER DRUGS?

Have you been through a rehabilitation facility or a Florida Recovery home before?

DATE OF LAST DRINK?

DRUG AND LAST DATE?

Reason for leaving:

Prior living situation:

Marital status:

How long?

Name of spouse:

Spouse address:

Are you involved in an intimate relationship with someone?

How long?

Name:

Address:

NUMBER OF CHILDREN:

Ages of children?

Where do your children live?

Do you have to pay child support?

Payment amount?

When?

Are you behind in paying?

How much?

When was the last time you saw your children?

FATHER:

First

Last

Address:

Age

Job:

Status:

Religion:

History:

Alcohol problem
Drug problem
Homeless

MOTHER:

First

Last

Address:

Age:

Job:

Status:

Religion:

History:

Alcohol problem
Drug problem
Homeless

BROTHER #1:

First

Last

Address:

Age:

Job:

Status:

Religion:

History:

Alcohol problem
Drug problem
Homeless

BROTHER #2:

First

Last

Address:

Age:

Job:

Religion:

Status:

History:

Alcohol problem
Drug problem
Homeless

BROTHER #3:

First

Last

Address:

Age:

Job:

Religion:

Status:

History:

Alcohol problem
Drug problem
Homeless

SISTER NAME #1:

First

Last

Address:

Age:

Religion:

Status:

History:

Alcohol problem
Drug problem
Homeless

SISTER NAME #2:

First

Last

Address:

Age:

Religion:

Status:

History:

Alcohol problem
Drug problem
Homeless

SISTER NAME #3:

First

Last

Address:

Age:

Religion:

Status:

History:

Alcohol problem
Drug problem
Homeless

ARE YOU PRESENTLY EMPLOYED?

Employed by?

How long?

Address:

Phone number:

Owner or immediate supervisor:

First

Last

Phone number:

Position:

Responsibilities:

What type of job skills do you have?

What other type of skills do you have?

1) PREVIOUS EMPLOYER:

Position:

Start & end dates:

Reason for leaving:

Attitude towards job:

2) PREVIOUS EMPLOYER:

Position:

Start & end dates:

Reason for leaving:

Attitude toward job:

3) PREVIOUS EMPLOYER:

Position:

Start & end date:

Reason for leaving:

Attitude towards job:

EDUCATION: How far did you get in school (grade)?

School:

Address:

Did you graduate?

Future education goals?

Ever attend a vocational or technical school?

Have you ever felt the call of God in Your Life?

Explain:

CRIMINAL HISTORY: Do you have any charges pending?

Court date:

Judge:

Hearing date:

Attorney name:

Attorney address:

Terms of probation:

PRIOR CRIMINAL HISTORY #1) Include Date / City / State / Charge / Disposition

PRIOR CRIMINAL HISTORY #2) Include Date / City / State / Charge / Disposition

PRIOR CRIMINAL HISTORY #3) Include Date / City / State / Charge / Disposition

PRIOR CRIMINAL HISTORY #4) Include Date / City / State / Charge / Disposition

PRIOR CRIMINAL HISTORY #5) Include Date / City / State / Charge / Disposition

PRIOR CRIMINAL HISTORY #6) Include Date / City / State / Charge / Disposition

RESIDENCY OR EMPLOYMENT INQUIRY RELEASE

In conjunction with my continued residency or employment with you, I understand that you may hire Selection.com to obtain “Consumer Reports” about me as defined in the Fair Credit Reporting Act (FCRA). These “Consumer Reports” may include information concerning my credit worthiness, credit standing, credit capacity, character, academic background, credentials, work habits, work performance, work experience, reasons for work termination, general reputation, personal characteristics or mode of living. You also may seek information concerning my employment history, workers’ compensation history, motor vehicle record, education background, civil litigation history and/or criminal record. I understand that you may rely on any or all of the above referenced information in determining my continued eligibility for residency or employment. If you contemplate making an adverse residency or employment-related decision that will affect me based, in whole or in part, upon a “Consumer Report” obtained from Selection.com, I will be provided with a copy of the “Consumer Report” and a written summary of my “Consumer Rights” under the FCRA before you finalize that decision. I have read the above disclosure and I hereby authorize you, Selection.com or its authorized agents to obtain the above referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above referenced knowledge or information they have concerning me. Furthermore, this authorization shall remain on file and shall serve as an ongoing authorization for you to obtain “Consumer Reports” about me from SMS at any time during my employment with you. A photocopy or facsimile of this authorization shall be as valid as the original.

Name:

First

Last

Date:

Witness:

THRONE OF GRACE LIFE CENTER BACKGROUND INVESTIGATION

THE FOLLOWING INFORMATION IS REQUIRED TO CONDUCT THE BACKGROUND INVESTIGATION

Name: Last Name, First Name, Middle Initial

Previous or maiden name: (if applicable)

Phone number:

Street address / City / State / Zip:

Driver's License Number:

State Issued:

List states and counties of residence, other than above, for the past seven (7) years:

Date of Birth:

My prospective employer understands age to be a protected characteristic and the information requested will not be used as the basis for any employment decision.

Notice to Applicants Living in CA, OK or MN By checking this box, I request to receive a free copy of any Report ordered on me. Email address: ** ** By entering my email address, I authorize Selection.com to deliver my Report via email

Notice to California Residents: Under section 1786.22 of the California Civil Code, you may view the file maintained on you by Selection.com during normal business hours. You may also obtain a copy of this file, either in person or by mail, by submitting proper identification and paying the costs of duplication services. You may also receive a summary of the file by telephone by being able to provide adequate identification as to allow Selection.com to determine with reasonable certainty that you are the subject of the report. Selection.com is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person, another person of your choice may accompany you, providing that this additional person furnishes proper identification. Customer Number: _ TGM101#00001____________________Location or Store Number Date Submitted Contact Person: Phone Number Position Applied For Information Requested: Combined Report: Individual Reports: ________________________________________________________________________________________________________________________ Criminal Convictions County(s) and state(s) Other: This Form Provided By: Selection.com 155 Tri County Parkway; Suite 150 Cincinnati, OH 45246 Telephone – 800.325.3609 Fax – 888.767.2435

MEDICAL HISTORY: Doctors name:

Doctors address:

Phone number:

When did you last see a doctor?

For what?

Have you been taking any Doctor prescribed medication in the last year?

What are you taking?

Present physical complaints or problems?

If yes to any of the above, explain:

Have you ever gone to counseling before?

For what problem?

Are you currently receiving help from anyone else?

Who?

First

Last

Where?

Have you ever attempted suicide?

Explain:

DO YOU CURRENTLY HAVE A DRUG OR ALCOHOL PROBLEM?

Have you used any drug or alcohol in the past 3 days?

What?

Have you ever been in treatment before?

Where?

Do you like getting high?

Do you feel this is a problem for you or your family?

Have you ever felt guilty or shame about your addiction?

Do you want help?

Your addiction is either a bad habit, a wounded soul, which is a reaction to some tragedy in your life or demonic activity. Of the three reasons above, which one is it for you? Explain.

This addiction can be broken by The Power of God, through Faith in Jesus Christ!

If you have faith as a mustard seed, you shall say to this mountain, move from here to there, and it will move; and nothing will be impossible for you.
Matthew 17:20

Contact

Office => (941) 753-2945
email => togchurch@verizon.net

Location

1408 55th Ave. West
Bradenton, FL 34207

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