Commonwealth of Massachusetts
Alcoholic Beverages Control Commission
95 Fourth Street, Suite 3
Chelsea, MA 02150
CORI REQUEST FORM
The Alcoholic Beverages Control Commission ("ABCC") has been certified by the Criminal History Systems Board to access
conviction and pending Criminal Offender Record Information ("CORI"). For the purpose of approving each shareholder, owner,
licensee or applicant for an alcoholic beverages license, I understand that a criminal record check will be conducted on me, pursuant
to the above. The information below is correct to the best of my knowledge.
LAST NAME: MIDDLE NAME:
MAIDEN NAME OR ALIAS (IF APPLICABLE): PLACE OF BIRTH:
ABCC NUMBER:
DATE OF BIRTH: ID THEFT INDEX PIN (IF APPLICABLE):
EYE COLOR:
FIRST NAME:
STATE: ZIP:
APPLICANT/EMPLOYEE SIGNATURE:
SSN:
MOTHER'S MAIDEN NAME:
CURRENT ADDRESS:
FORMER ADDRESS:
CITY/TOWN:
STATE: ZIP:CITY/TOWN:
WEIGHT:
GENDER: HEIGHT:
REQUESTED BY:
SIGNATURE OF CORI-AUTHORIZED EMPLOYEE
The DCJI Identify Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft
PIN Number by the DCJI. Certified agencies are required to provide all applicants the opportunity to include this
information to ensure the accuracy of the CORI request process. ALL CORI request forms that include this field are
required to be submitted to the DCJI via mail or by fax to (617) 660-4614.
to be the person whose name is signed on the preceding or attached document, and acknowledged to me that (he) (she) signed it voluntarily for
its stated purpose.
On this
before me, the undersigned notary public, personally appeared
(name of document signer), proved to me through satisfactory evidence of identification, which were
NOTARY
JEAN M. LORIZIO, ESQ.
CHAIRMAN
DRIVER'S LICENSE #:
LICENSEE NAME:
STATE LIC. ISSUED:
PRINTED NAME:
CITY/TOWN:
NOTARY INFORMATION
PRINT AND SIGN
APPLICANT INFORMATION
ABCC LICENSE INFORMATION
DIVISION USE ONLY
(IF EXISTING LICENSEE)
click to sign
signature
click to edit
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