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2. 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.
4. APPLICANT INFORMATION:
6. 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.

   1. Employment with the City of Rockville
   2. Volunteer
   3. Contractor
8. Volunteering/Contracting Program
   -- Select One --C.A.R.E. Actor LLC (Act It Out & Dramatic Kids)Cheer MadnessCoach Doug AcademyCommunity CentersCrisscross Applesauce LLC dba Abrakadoodle of Montgomery CountyCroydon Creek Nature CenterDansez! Dansez!DEILAB, Inc.Environmental ProgramsFencing AcademyFunfit – Funfit Foundation Inc.Four on the Floor Dog Training, LLCGlobal Children’s Center (Young Chefs & Manners)Higher Level Girls BasketballJazzerciseKicks KarateLearn Now MusicMC Elite LacrosseMentoring ProgramRockville Baseball Association (RBBA)Rockville Community Baseball (Rockville Express Baseball)Rockville Football League (RFL)Rockville Science Center (Robotics)Thrive YogaTriumph Communication, Inc. dba Mad Science UK Elite SoccerVolunteer Swim Instructor Aid at RSFCWet Yet Water FitnessXtremo Acro CheerYouth BasketballYouth Cross CountyYouth Coach PitchYouth SoccerYouth T-ballYouth Track and FieldYouth WrestlingZen Budo KarateOthers

   Select the Volunteering/Contracting Program (if volunteer or contractor was checked above)

10. Position Title of Employment
    Enter the Position Title (if employment with the City of Rockville was checked above)
11. City of Rockville Supervisor or Contact*
    Please enter the name of the person with the City of Rockville that will be your supervisor or has been your contact
13. First Name*
    Please provide your legal name as shown on a driver’s license or other government issued identification.
14. Middle Initial
15. Last Name*
16. Suffix
18. Date of Birth*
    Date of Birth
19. Gender*
    -- Select One --Female (F)Male (M)Unknown (U)
20. Former Name/Alias
22. Place of Birth*
    (State or Country)
23. Citizenship*
    (Country)
25. Daytime Phone*
    (xxx-xxx-xxxx)
26. Email Address*
27. SSN Upload*

    The background check runs on SSN. Please upload an image of your SSN.

29. Street Address*
30. City*
32. State*
33. Zip*
34. Country*
36. Previous Address
38. Screening Disclosure & Authorization*

    1. Check box if you have read and authorized the screening process.
39. 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.
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field