Fill - Free fillable Commonwealth of Massachusetts CORI Acknowledgement Form PDF form

1

TobeusedbyorganizationsconductingCORIchecksforemployment orlicensing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, or current licensees.

Asaprospectiveorcurrentemployee,subcontractor,volunteer,licenseapplicant or currentlicensee,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.

I also understand, that________________________________________________________________mayconduct

(Organi

zation)

subsequentCORIcheckswithinoneyearofthedatethisFormwassignedbyme.

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C

ORISubject

_________________________________

Date

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

This form is not to be faxed. Please return form to organization .

CriminalOffenderRecordInformation(CORI)

Acknowledgement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

2

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Numb

er: ______‐‐____________ ☐NoSocialSecurityNumber

Sex: _________________ Height: _____ft. _____in. EyeColor:_______________ Race: ______________________

Driver’sLicenseorIDNumb

er:______________________________________ StateofIssue:____________________

Father’sFullName: ___________

_____________________________________________________________________

Mother’sFullName: ____

___________________________________________________________________________

CurrentAddress

* 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:

______________________ ____________________________________________________________________________

Verifiedby:

___________________________________________________________

PrintNameofVerifyingEmployee

___________________________________________________________ _________________________________

SignatureofVerifyingEmployee Date

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Commonwealth of Massachusetts CORI Acknowledgement Form

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Fillable Commonwealth of Massachusetts CORI Acknowledgement Form

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