Notification and Authorization to Release Criminal
Information for Employment Purposes
The position for which you are being considered requires your consent to a criminal background check as a
condition of employment. This check includes the following: Criminal history reference searches for felony and
misdemeanor convictions.
I hereby authorize County of Montgomery Human Resources Department to conduct the criminal background check
described above. In connection with this, I also authorize the use of law enforcement agencies to assist the County
of Montgomery Human Resources Department in collecting this information.
I also am aware that records of arrests on pending charges and/or convictions are not an absolute bar to employment.
Such information will be used to determine whether the results of the background check reasonably bear on my
trustworthiness or my ability to perform the duties of my position in a manner which is safe for County of
Montgomery employees and the general public.
Position Applied for: Department :
Please print (for identification purposes):
Full Legal Name:
First Middle Last
Other Names You Have Used in Past Seven Years:
Current Address:
Date of Birth: Gender: Female Male
Social Security Number:
Driver’s License # State of Driver’s License
Have you ever been convicted of a criminal *offense or have any pending criminal* charges against you?
*This refers only to felonies and misdemeanors; you do not need to include non-criminal traffic violations or
municipal ordinance violations.
Yes (provide detail on next page) No
To the best of my knowledge, the information provided in this Notice and Authorization and any attachments thereto
is true and complete. I understand that any falsification or omission of information may disqualify me for this
position and/or may serve as grounds for the severance of my employment with County of Montgomery. By signing
below I hereby provide my authorization to County of Montgomery Human Resources Department to conduct a
criminal background check. If a record exists, I shall have ten (10) business days, after receipt of notice and the
photocopy of the conviction history report from the County, to respond to the County with evidence of mitigation,
error or rehabilitation. The County shall review all information and documentation received prior to making any
final decision.
Signature Date