Apply for Dentures – God Smile Ministry

God Smile Ministry assists men and women in the Owensboro – Daviess County community.

Your Name*
First Middle Last
Your Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email
Your Sobriety Date*
MM slash DD slash YYYY
Employer*
How long have you been employed?*
What are your short term sobriety goals?*
(3-6 months)
What are your long term sobriety goals?*
(1-5 years)
Tell us about your struggle with addiction and your road to recovery.*
Do you have teeth that need to me removed?*
God Smile Ministry does not assist with the teeth removal. Twelve weeks after removal you will be scheduled to see our dentist if you are accepted after the interview process.
- Yes
- No
Can you contribute financially towards your smile?*
- Yes
- No
How much are you able to contribute and when can you make that contribution?*
Are you willing to help with God Smile Ministry?*
- Yes
- No
Do you give permission for your information, personal story and picture to be used on social media or brochures?*
- Yes
- No
References
Please list three references that we are able to contact by phone that would support that you are a good candidate for God Smile Ministry.
Name*
First Last
Company
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Relationship*
Name*
First Last
Company
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Relationship*
Name*
First Last
Company
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Relationship*
Acknowledgement
I certify that my answers are true and complete to the best of my knowledge.
Digital Signature*
Printing your First Name + Middle Initial + Last Name will act as your digital signature.
CAPTCHA

God Smile Ministry

References

Acknowledgement

God Smile Ministry