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Upon receiving this application, the Stafford SPCA will make a decision on whether you will qualify to serve CSV hours

with us. If you are approved, we will contact you for an intake interview to discuss our program in more detail, to

determine your hourly supervisory fee, and to schedule your hours. Hours will be scheduled in advance and will be

binding once they are scheduled. The Stafford SPCA can be very flexible in scheduling your community service hours

around your existing schedule.

Initial the sections below to indicate you agree and understand.

_____

If the Stafford SPCA contacts me to schedule an intake interview and I fail to show for the interview, I will be

assessed a $20 NO SHOW FEE. This fee must be paid before any community service hours begin. If I am unable to keep my

intake interview appointment, I will provide at least 24 hours’ notice.

_____ The Stafford SPCA has a zero-tolerance policy regarding smoking, alcohol, and drugs. I agree NOT to smoke on

Stafford SPCA property, either inside or outside. This includes the driveway and parking lot area. I understand that

smoking on the property is grounds for immediate dismissal. This policy applies at all times.

_______ I understand that completing the application process does not guarantee acceptance as a community service

volunteer.

_______ I understand that there is an hourly supervisory fee that will be charged. The amount of this fee will be decided

and set during the intake interview. This fee must be paid IN FULL before my community service hours can begin at the

Stafford SPCA. This fee is non-refundable and will be applied to the Stafford SPCA general operating fund.

_______ If I am under 18 years old, I must bring a parent or legal guardian to the intake interview with me.

______ I certify that the information in this application is correct to the best of my knowledge and belief. I authorize agents

of the Stafford SPCA to check with the appropriate authorities regarding my criminal background history. I understand that,

should I be offered the opportunity to complete my court ordered community service hours, any misrepresentation by me

may lead to termination, and my being barred from any future opportunity to volunteer with the Stafford SPCA. I also

understand that my community service can be terminated with or without cause and/or notice at any time by the Stafford

SPCA. I hereby give permission for my attorney, probation officer, and any other parties to communicate and share freely

with the Stafford SPCA any information regarding myself and my history.

_______________________________________________________

_____/______/_____

Signature

Date

_______________________________________________________

_____/______/_____

Parent or guardian signature (required if applicant is under 18 years old)

Date

Email this completed form to:

OR fax this completed form to 866-522-8042

Stafford SPCA staff use only

RECEIVED BY: ________________________ on _____________ BKG: _________ INTAKE SCHEDULED: ___________

NOTES: ________________________________________________________________________________________

_______________________________________________________________________________________________

Stafford SPCA

CSV Supervisor, 540-242-0608

Updated 8/2/2015

Court Ordered Community Service Application Form - Spca - Stafford County - Virginia Page 3