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City
of
Brockton
BROCKTON PUBLIC SCHOOLS
Matthew
H.
Malone 4 Superintendent of Schools
Dr. Kathleen
F.
Moran, Executive Director
Office
of
Human Resources
P/1one (508) 580-7535 Fax (508) 580-7091
The Brockton Public Schools
is
registered under the provisions ofM.G.L,
c.
6,
§172
to
receive CORI for the
purpose of screening
current
and otherwise qualified prospective employees, subcontractors, and volunteers.
As
a prospective
or
current employee, subcontractor, volunteer
or
chaperone, I understand that a CORI check
will
be submitted for
my
personal information to the DCJIS. I hereby acknowledge and provide permission
to
Brockton
Public Schools
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 Brockton Public
Schools with written notice of
my
intent
to
withdraw consent to a CORI check.
FOR
EMPLOYMENT
AND
VOLUNTEER PURPOSES ONLY: The Brockton Public Schools may conduct
subsequent
CORI
checks within one year of the date this form was signed
by
me provided, however, that Brockton
Public Schools must first provide me with written notice of this check.
By signing below, I provide my consent to a CORI check and acknowledge
that
the information provided on this
acknowledgement form
is
true and accurate.
Signature
Date
Last Name First Name Middle Name
Suffix
Maiden Name (or other name(s) by which you have been known)
Date of Birth:
---------------
Place of Birth:
Last
Six
Digits of your social security number:
Sex:
______
Height:
Ft.
In. Eye Color:
Race:
Driver's License or
ID
Number: State of!ssue:
Mother's Full Maiden Name
Father's
Full Name
Current
and Former Addresses:
Street Number and Name City/Town State
ZIP
Street Number and Name City/Town State
ZIP
The
a.hove
information was verified by reviewing the
following form(s)
of
government issued identification:
Name of Verifying Employee
(Please Print):
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Signature:
Requested
by:
Created
9/2012
click to sign
signature
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