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Application for Services

Please fill out the following form online, or click here to download a printable application that can be filled out by hand.

Personal Identification
Full Name
Date of Birth
Place of Birth
Telephone
Social Sec. No.
U.S. Citizen? Yes No
Other Status
Personal Identity Documents
Check all documents that you have:
Birth Certificate
Virginia Drivers License (expired)
Virginia Personal Identification Card
Criminal Justice Agency Offender Information Form
Social Security Card
US Passport
Other Passport
Employer Check Stubs (two most recent)
Family Information
Married? Yes No    Spouse Name
Living Together? Yes No    Name
Number of dependents
Child support orders (fill out completely):
Name $ / mo.
 
 
 
 
 
Household Income (take-home pay of all residents)  $ per mo.
Legal Residence
Street Apt
City-State-Zip
Home Phone
Cell Phone
Email Address
Do you: Own  Rent  (check one)
If you rent, provide contact information:
- Contact Name
- Contact Phone
How long at this address? (mo/yr)
Employment / Job Training Program
Employed? Yes No -- How long?
Job Training? Yes No -- How long?
Employer/Prgm Name
Employer/Prgm Address
- Supervisor Name
- Supervisor Phone
Your Position
Your Salary $ per month / $ per hour
Working Hours   Hrs / week
How do you get there?
Time traveling (per day)
Outstanding Garnishments
Driving Record
Past Virginia driver's license? Yes No -- License #
Present License Status:
Restrictions/Offenses (check all that apply):
Driving Under Influence (DUI)
Suspend - Not Paying Child Support
Suspend - Not Paying Fines and Costs
Reckless/Aggressive Driving, etc.
Other Restrictions:
Do you have your DMV Driver History Transcript? Yes No
Do you have your DMV Compliance Summary? Yes No
Pending Traffic Cases
Date Charge Court
     
     
     
     
     
Criminal Offender Record (if applicable)
List of Convictions
(offense & sentence):
Time Served Yrs
Place of Incarceration  Release Date
Parole/Probation Officer
Phone
- Court
Do you have CCRE Report from State Police? Yes No
I Certify
By checking the box above, I certify that all the information in this Application is true and correct. I further understand that no services are promised or will be rendered until this Application is accepted. For services to be provided, a retainer agreement must be signed and any required fees must be paid.

Remember to send:
- DMV Request Form
- $20.00 Check or Money Order
 
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