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Name

First Middle Last

Social Security Number

Address

Street/P.O. Box/Apt. #

City

State

Zip Code

1. 1. Have you ever been convicted of a crime within or outside Virginia (but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law)?

Yes

If yes, list all and explain

2. Are you the subject of any pending criminal charges within or outside Virginia?

Yes

If yes, list all and explain

3. Have you ever been the subject of a founded complaint of child abuse or neglect within or outside Virginia:

Yes

If yes, list all and explain

4. I hereby affirm that the information provided on this form is true and complete, I understand that the information is subject to verification.

Date

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Office Number

240-869-9325

Fax Number

571-589-0141

Email Address

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3453 Castle Hill Dr,

Woodbridge, VA 22193

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VA Sworn Disclosure

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Contact Us

Office Number

Fax Number

Email Address

3453 Castle Hill Dr,

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Counties

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