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Court Ordered Community Service Application

Please print legibly. All applicable fields are required if you wish to be considered for

our community service program.

Your information:

Full Name: ______________________________________________________________________________________

First

Middle

Last

Other names used (maiden name, etc.): ______________________________________________________________

Date of birth: ________/________/___________

Social security number: _________________________________

Driver’s license number: _______________________________________

State issued: _______________

Current Address: _______________________________________________________________________________

City:_______________________

County: __________________

State:_____

Zip: _______________

Home phone (_______) ________-_____________

Cell phone: (_______)________-_________________

Personal email address: __________________________________________________________________________

Emergency contact information:

If the person to perform service is under the age of 18, a parent or legal guardian must attend the intake interview with you.

Please use this emergency contact field to list the information for the parent/legal guardian who will be attending the interview.

For all applicants over the age of 18, use this field for the best person to contact in the event of an emergency.

Emergency contact name: _______________________________________________________________________

Emergency contact address: ______________________________________________________________________

Emergency contact date of birth (required if the applicant is under 18 years old): ________/________/_________

City:_______________________

County: __________________

State:_____

Zip: _______________

Emergency Contact Phone Numbers: Home: (_______) ________-__________ Cell: (_______) ______ - ____________

Court Information and background information:

Detail your current charge(s) that require court ordered community service hours. Please describe as needed.

______________________________________________________________________________________________

Stafford SPCA

CSV Supervisor, 540-242-0608

Updated 8/2/2015

Court Ordered Community Service Application Form - Spca - Stafford County - Virginia