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2. If you need this form in another format, please contact our ADA (Americans with Disabilities) Coordinator at 240-314-8108, email jhomer@rockvillemd.gov, TTY-240-314-8137 or Relay 711. The city welcomes requests for reasonable modifications for persons with disabilities who wish to serve on a Board, Commission, Committee or Task Force.

4. First Name
5. Last Name
7. Address*
9. City
10. State
11. Zip
13. Phone*
14. Email*
16. What board, commission, committee or task force are you interested in serving on?*
18. Do you currently serve on a board, commission, committee or task force?*

    1. Yes
    2. No
20. Please describe your interest in serving *
22. Required Resume
    Resume should include:

    • Relevant Work Experience
    • Education
    • Volunteer Experience
    • Skills
    Professional Affiliations/Memberships
24. Upload Resume*
26. Please indicate YES or NO whether or not the city may disclose this Expression of Interest Form and any accompanying resume or other information that you provide to the public. Your address and phone number(s) will not be included. *

    1. Yes
    2. No
28. Please indicate YES or NO whether or not the City may give elected officials who serve Rockville (other than Mayor and Council) your name and address. This information will not be used for any fundraising or campaign mailings. No phone numbers will be given.*

    1. Yes
    2. No
30. By submitting this Expression of Interest Form and any accompanying resume or other information, you agree to the release of this information to the Mayor and Council, to the board, commission, committee or task force to which you are applying and to its staff liaison.
    
    Type your full name as an electronic signature to agree to the terms.*
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32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field