Fillable CORI Individual Agreement Of Non- Disclosure (Commonwealth of Massachusetts)

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CORI Individual Agreement Of Non- Disclosure (Commonwealth of Massachusetts)

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File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Criminal Record Information (CORI and CHRI)
Individual Agreement of Non-Disclosure
I, , acknowledge that I have read and
understand the provisions of Massachusetts General Laws, c. 6, §§ 167-178B, of which section
178 provides that it is a criminal offense for an individual or entity to “knowingly request, obtain
or attempt to obtain criminal offender record information or a self-audit from the department under
false pretenses, knowingly communicate or attempt to communicate criminal offender record
information to any other individual or entity except in accordance with the provisions of sections
168 through 175, or knowingly falsify criminal offender record information, or any records relating
thereto, or to request or require a person to provide a copy of his or her criminal offender record
information except as authorized pursuant to section 172.” Unauthorized access to, or
dissemination of, criminal offender information or a self-audit is punishable by a fine of not more
than five thousand dollars ($5,000.00), or imprisonment in a jail or house of correction for not
more than one year, or both. If the offender is anyone other than a natural person, the fine may be
increased to fifty thousand ($50,000.00) for each offense. Any such violation also subjects me to
a suit for civil damages and/or a civil fine of up to five thousand dollars ($5,000.00) for each such
violation. Furthermore, I acknowledge that I have read and understand the provisions of 28 C.F.R.
20.33 and the most recent version of the FBI CJIS Security Policy relating to access and
dissemination of Federal Bureau of Identification (FBI) Criminal History Record Information
(CHRI). Pursuant to 28 C.F.R. 20.33, I understand that CHRI may only be accessed and
disseminated for one of the purposes set forth in 28 C.F.R. 20.33 and also understand that the
penalty for a violation of said regulations may subject me to a civil fine of up to eleven thousand
dollars ($11,000.00), pursuant to 28 C.F.R. 20.25.
I also understand that a criminal record check will be conducted on me by the Criminal Justice
Agency and/or the Department of Criminal Justice Information Services as a prerequisite to my
having authorization to access CORI and/or CHRI.
Signed this day of , 20 .
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Application for Access to CORI/CHRI
(Please Type or Print – this application MUST be completed in conjunction with the
Criminal Record Information (CORI/CHRI) Individual Agreement of Non-Disclosure)
Last Name First Name
Middle Name or Initial Suffix (Sr., Jr, III, etc.)
Maiden Name
Previous/Alias Names (if applicable):
XXX - -
Date of Birth Social Security Number (last 6 only)
Job Title
Agency/Business Name
Agency Address (Street Number, Street Name, City, State, and Zip Code)
This document is to be completed by ALL persons employed by, contracted with, or otherwise
operating in association with the herein names agency and who may have access to criminal
history record information (CHRI/CORI). All fields (except Middle Initial, Suffix, Maiden
Name, and Previous/Alias Names) are required.
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CORI Individual Agreement Of Non- Disclosure (Commonwealth of Massachusetts)

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Completed 27 July 2020

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