Fill - Free fillable CORI Acknowledgment & Authorization Form 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

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1



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prospectiv e

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personal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.

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FOREMPLOYMENT,VOLUNTEER,ANDLICENSINGPURPOSESONLY:



The_______________________________________________________________________________mayconduct

 (Organization)

subsequentCORI

checks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





The City of Brockton

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

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2

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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: __________________________________________________________________________ _____

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 FormerLastName4: __________________________________________________________________________ _____

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* DateofBirth(MM/DD/YYYY): ___________________ PlaceofBirth:________________________________________

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* 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:____________________

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 Father’sFullName: ________________________________________________________________________________

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 Mother’sFullName: _______________________________________________________________________________



CurrentAddress

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* StreetAddress:____________________________________________________________________________________



 Apt.#orSuite: _____________ *City:__________________________ *State: ________ *Zip:_______________ 

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SUBJECTVERIFICATION

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Theaboveinformationwasverifiedbyreviewingthefollowingform(s)ofgovernment‐issuedidentifica tion:

__________________________________________________________________________________________________



Verifiedby:



___________________________________________________________

 PrintNameofVerifyingEmployee 



___________________________________________________________ _________________________________

 SignatureofVerifyingEmployee Date

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