Fill - Free fillable Bristol Community College - CORI Acknowledgement PDF form



    

 

              



    



                  

              



               

                     

      



                      

           



            

      

   



 

               

    



     

                     

     

  

    

___________________________________________________________ _________________________________

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: ______________________________________________________________________________________

Bristol Community College



 

              

         

    

     

   

       

               

          

        

  

 

         

 

            

 

 



    

  

    

__________________________________________________________________________________________________

___________________________________________________________

___________________________________________________________ _________________________________

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 government‐issued identification:

Fill Online, Printable, Fillable, Blank Bristol Community College - CORI Acknowledgement Form

Related forms

Fillable Bristol Community College - CORI Acknowledgement

Fill Online, Printable, Fillable, Blank Bristol Community College - CORI Acknowledgement Form

Related forms

First 20 documents completely FREE!