1. This application may be completed and submitted on-line, or printed, completed by hand and delivered to the jail site. If the application is completed by hand, please print legibly using a blue or black ink pen.
2. Be sure to fill in all of the blanks. Failure to do so may delay the processing of your application.
3. Be prepared to provide address and employment history for the past seven (7) years. You are also asked to provide three (3) references.
4. If you are a religious volunteer, please identify your religious affiliation.
5. When submitting your application in person, you will be asked to provide a copy of your:
   1. Driver’s license
   2. Social security card
6. Upon approval, a background investigation will be conducted. You will need a current Virginia driver’s license.
7. Before submitting your application, please review it to ensure you provided all of the information requested and signed on the appropriate blanks.

Last Name  
First Name  
Middle Name
Maiden Name
Street Address  
City  
State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip  
Home Phone  
Work Phone
Cell Phone
Date of Birth  
Race
Sex MaleFemale
Driver’s License No  
State of Issue AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Social Security No.  
For Religious Volunteers, Specify religious affiliation

Name  
Relationship  
Street Address  
City  
State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip  
Home Phone  
Work Phone
Cell Phone

List three (3) personal references, preferably local. Do not use former employers or relatives. Addresses must be complete and accurate. If applying to assist with religious activities, please include a member of the clergy as a reference.

	Name	Full Address	Telephone number(s)
	1.
	2.
	3.

Have you ever been arrested, taken into custody or convicted of any offense(s)? YesNo

List prior Volunteer experience

Facility

Address

Type of Volunteer Service

If current &/or prior experience is at a correctional facility, please list first.
List type of Volunteer work you are interested in at PCRJ:
How often do you plan to be at the facility?

		Daily	Weekly	Bi-monthly	Monthly
	Days/Times Available:
	Referred by:

Have you ever worked in any correctional facility? YesNo

If you will provide a professional service, please indicate the certificate or license you hold:

Signature Verification

______________________________________
Volunteer Name (printed)

I hereby release the Peumansend Creek Regional Jail Authority (PCRJA), its officers, agents and employers from any and all liability for any injuries and damages that may be incurred.

By my signature, I acknowledge I am the above named person. I affirm all questions have been fully answered and every answer is true and correct to the best of my knowledge.

Volunteer Signature Date Witness Signature Date

	To:	Any person, organization or agency having knowledge of my conduct or activities, or any past or present employer; or Any credit bureau, retail merchants association, bank, financial institution or any other credit extending organization; or Any dean, registrar, principal, counselor, instructor or other authorized person at a school, (university, college, high school, trade school or other); or Any doctor, hospital, clinic or sanatorium; or Any department or agency of a city, county or state government or of the federal government.
	By my signature below, I hereby authorize the Peumansend Creek Regional Jail Authority to conduct an appropriate background investigation including, but not limited to, personal interviews for determination of my eligibility to occupy a position of trust. I authorize all persons who may have information relevant to this background investigation to disclose it to the Peumansend Creek Regional Jail Authority or its agents and I release all persons from liability on account of such disclosure.
	I further consent to a photocopy of this authorization be considered as valid as an original.

Last Name  
First Name  
Middle Name
Maiden Name
Street Address  
City  
State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip  
Home Phone  
Work Phone
Cell Phone


Volunteer Signature Date Witness Signature Date