Montgomery County
Animal Care and Adopon Center
480 Cinnabar Rd, Chrisansburg, VA
Court‐Ordered Community
Service Applicaon
Name
Vol. Coordinator Signature Date
Office Use Only
Shelter Supervisor Signature Date
Personal Informaon
Phone 1
Address
Phone 2
City State Zip
Driver’s License
E‐mail Address
Supervisor Informaon (Parole Officer, etc.)
Name Phone 1
Organizaon
Phone 2
E‐mail Address
Signature of Parent/Guardian Date
Volunteer Signature (Over 18) Date
Approved Denied Supervisor Contacted
Date & Inials
How many hours are you required to complete?
Please describe your charges below.
Have you ever been charged with/convicted of animal neglect, abandonment, or cruelty?
Yes No
Have you ever been charged with/convicted of assault, sexual assault, or other violent crime?
Yes No
