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___________________________________________________________ _________________________________
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973
MASS.GOV/CJIS
Criminal Offender Record Information (CORI)
Acknowledgement Form
To be used by organizations conducting CORI checks for employment, volunteer, subcontractor, licensing, and housing
purposes.
_______________________________________________________________________________ is registered under the
(Organization)
provisions of M.G.L. c.6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective
employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of
housing.
As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, or applicant for the
rental or lease of housing, I understand that a CORI check will be submitted for my persona l information to the DCJIS. I
hereby acknowledge and provide permission to __________________________________________________________
(Organization)
to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my
signature. I may withdraw this authorization at any time by providing _________________________________________
(Organization)
with written notice of my intent to withdraw consent to a CORI check.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:
The _______________________________________________________________________________ may conduct
(Organization)
subsequent CORI ch
ecks within one year of the date this Form was signed by me, provided, however, that
_______________________________________________________________________________, must first provide me
(Organization)
with written notice of this check.
By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of this
Acknowledgement Form is true and accurate.
Signature of CORI Subject Date
Please indicate your status with Bristol Community College
by providing program of study (student), position title (employee), or volunteer title:
Title: ______________________________________________________________________________________
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Bristol Community College
Bristol Community College
Bristol Community College
Bristol Community College
Bristol Community College
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__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________
___________________________________________________________ _________________________________
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973
MASS.GOV/CJIS
SUBJECT INFORMATION
Please complete this section using the information of the person whose CORI you are requesting.
The fields marked with an asterisk (*) are required fields.
* First Name: ________________________________________________________ Middle Initial: _________________
* Last Name:_________________________________________________________ Suffix (Jr., Sr., etc.): _____________
Former Last Name 1: _______________________________________________________________________________
Former Last Name 2: _______________________________________________________________________________
Former Last Name 3: _______________________________________________________________________________
Former Last Name 4: _______________________________________________________________________________
* Date of Birth (MM/DD/YYYY): ___________________ Place of Birth: ________________________________________
* Last SIX digits of Social Security Number: ___ ___‐‐ ___ ___ ___ ___ No Social Security Number
Sex: _________________ Height: _____ ft. _____ in. Eye Color: _______________ Race: ______________________
Driver’s License or ID Number: ______________________________________ State of Issue: ____________________
Father’s Full Name: ________________________________________________________________________________
Mother’s Full Name: _______________________________________________________________________________
Current A ddress
* Street Address: ____________________________________________________________________________________
Apt. # or Suite: _____________ *City: __________________________ *State: ________ *Zip: _______________
SUBJECT VERIFICATION
The above information was verified by reviewing the following form(s) of governmentissued identification:
Verified by:
Print Name of Verifying Employee
Signature of Verifying Employee Date
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