Looking for a Application Form Templates? Download it for free!

Number of hours required: _______________

Deadline for completion: ________/________/_________

Court of Jurisdiction: _______________________________________________________

Your attorney’s name, if applicable: ____________________________________________

Attorney’s Phone (_______) ________-__________

Attorney’s Fax: (_______) ________-__________

Your probation officer’s name, if applicable: ___________________________________

Probation officer’s phone: (_______) ________-__________ P.O. Fax: (_______) ________-__________

Have you ever pleaded or been found guilty of a felony or misdemeanor, besides the charge for which you are

currently required to fulfill community service hours?

Yes / No

If yes, please explain when, where and describe the details of your conduct:

(Attach more pages if needed. Answers must be complete and accurate.)

Date:_____/______/_____

Charge________________________________________________________________

Date: _____/______/_____

Charge________________________________________________________________

Date: _____/______/_____

Charge________________________________________________________________

The Stafford SPCA reserves the right to reject or refuse any applicants at its sole discretion. Convicted sex offenders are not permitted

in our program. Applicants convicted of larcenies or any violent offenses will be evaluated on a case-by-case basis. As a state

recognized animal releasing agency, we are prohibited from accepting community service volunteers (henceforth “CSVs”) charged with

animal abuse, neglect, cruelty, or abandonment. The Stafford SPCA runs complete background checks on CSV applicants before

scheduling intake interviews.

Medical and health information:

Do you have any health or medical issues in case of an emergency? Allergies? Heart? Psychological? Other? List

below: ______________________________________________________________________________________

_____________________________________________________________________________________________

Are you—or is there a possibility you may be—pregnant?

Yes / No

List any medication(s) that you are currently taking that may impact your ability to serve CSV hours:

______________________________________________________________________________________________

Do you have allergies to animals? Yes / No

If yes, are allergies controlled by medication? Yes / No

REMINDER: It is your responsibility to take medications to treat allergies prior to serving community service hours.

Medications will not be dispensed by Stafford SPCA employees or management.

Stafford SPCA

CSV Supervisor, 540-242-0608

Updated 8/2/2015

Court Ordered Community Service Application Form - Spca - Stafford County - Virginia Page 2