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
1
CriminalOffenderRecordInformation(CORI)
AcknowledgementForm
TobeusedbyorganizationsconductingCORIchecksforemployment,volunteer,subcontractor,licensing,andhousing
purposes.
_______________________________________________________________________________is registeredunderthe
(Organization)
provisionsofM.G.L.c.6,§172toreceiveCORIforthepurposeofscreeningcurrentandotherwisequalifiedprospectiv e
employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of
housing.
Asaprospectiveorcurrentemployee,subcontractor,volunteer,license
applicant,currentlicensee,orapplicantforthe
rentalorleaseofhousing,Iunderstand thataCORIcheckwillbe submittedformypersonalinformationtotheDCJIS.I
herebyacknowledgeand providepermissionto__________________________________________________________
(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.Imaywithdrawthisauthorizationatanytimebyproviding _________________________________________
(Organization)
withwrittennoticeofmyintenttowithdrawconsenttoaCORI check.
FOREMPLOYMENT,VOLUNTEER,ANDLICENSINGPURPOSESONLY:
The_______________________________________________________________________________mayconduct
(Organization)
subsequentCORI
checkswithinoneyearofthedatethisFormwassignedbyme,provided,however,that
_______________________________________________________________________________,mustfirstprovideme
(Organization)
withwrittennoticeofthischeck.
By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of
this
AcknowledgementFormistrueand accurate.
___________________________________________________________ _________________________________
SignatureofCORISubject Date

The City of Brockton
The City of Brockton
The City of Brockton
The City of Brockton
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
2
SUBJECTINFORMATION
PleasecompletethissectionusingtheinformationofthepersonwhoseCORIyouarerequesting.
Thefieldsmarkedwithanasterisk(*)arerequiredfields.
* FirstName:________________________________________________________ MiddleInitial: _________________
* LastName:_______________ __________________________________________ Suffix(Jr.,Sr.,etc.): _____________
FormerLastName1: __________________________________________________________________________ _____
FormerLastName2: __________________________________________________________________________ _____
FormerLastName3: __________________________________________________________________________ _____
FormerLastName4: __________________________________________________________________________ _____
* DateofBirth(MM/DD/YYYY): ___________________ PlaceofBirth:________________________________________
* LastSIXdigitsofSocialSecurityNumber: ______‐‐____________ NoSocialSecurityNumber
Sex: _________________ Height: _____ft. _____in. EyeColor:_______________ Race: ______________________
Driver’sLicenseorIDNumber:______________________________________ StateofIssue:____________________
Father’sFullName: ________________________________________________________________________________
Mother’sFullName: _______________________________________________________________________________
CurrentAddress
* StreetAddress:____________________________________________________________________________________
Apt.#orSuite: _____________ *City:__________________________ *State: ________ *Zip:_______________
SUBJECTVERIFICATION
Theaboveinformationwasverifiedbyreviewingthefollowingform(s)ofgovernmentissuedidentifica tion:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Verifiedby:
___________________________________________________________
PrintNameofVerifyingEmployee
___________________________________________________________ _________________________________
SignatureofVerifyingEmployee Date
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