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Application for NCIS Background Check

  1. The screening process for City of Rockville employment, volunteer or contractor positions may include one or more of the following:

    A background search to verify previous work experience and professional/educational credentials using the social security number and date of birth you’ve provided.

    A motor vehicle records check to determine whether the candidate is suitable to operate a motor vehicle during the performance of their regular duties.

    CDL medical examination screening through Adventist HealthCare. The US Department of Transportation (DOT) regulates medical standards for holders of commercial driver’s licenses (CDL Drivers).

    DOT drug and alcohol screening through Adventist HealthCare. In addition to a physical examination, all drivers are subject to DOT drug/alcohol screening requirements.
  3. Reason for Background Check*
    Note: If you are NOT going to be employed with, volunteer to, or contracted through the City of Rockville please use the City of Rockville Police Department's fingerprinting form.
  4. Enter the Position Title (if employment with the City of Rockville was checked above)
  5. Please enter the name of the person with the City of Rockville that will be your supervisor or has been your contact
  6. Please provide your legal name as shown on a driver’s license or other government issued identification.
  7. (State or Country)
  8. (Country)
  9. (xxx-xxx-xxxx)
  10. The background check runs on SSN. Please upload an image of your SSN.

  11. Screening Disclosure & Authorization*
  12. I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any consumer report of which I am the subject upon written request. I also understand that I may receive a written summary of my rights in accordance with 15 U.S.C. §1681 et. Seq. I agree that this authorization shall remain valid for the duration of my employment, volunteering, and contract with the City of Rockville. I certify that the information contained on this authorization form is true and correct and that I may be subject to adverse action, up to and including termination based on any false, omitted or fraudulent information.
  13. Leave This Blank:

  14. This field is not part of the form submission.