Montgomery County
Animal Care and Adopon Center
480 Cinnabar Rd, Chrisansburg, VA
CourtOrdered Community
Service Applicaon
Vol. Coordinator Signature Date
Oce Use Only
Shelter Supervisor Signature Date
Personal Informaon
Phone 1
Phone 2
City State Zip
Driver’s License
Email Address
Supervisor Informaon (Parole Ocer, etc.)
Name Phone 1
Phone 2
Email 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