Your Name (required)
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Church You Attend
Areas in which you have served at church:
Do you have a criminal record of any type?
If yes, what were the charges?
Are you currently on parole?
Please provide two character references:
Please give us a brief testimony about your conversion and current relationship with Christ.
Do you understand each statement above?
Comments or Questions?
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Roseburg Rescue Mission provides food, shelter and recovery care to men, women and children in need.
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The hope you give today can change the life of a hurting person forever.