JV-083 (Rev. 01/20/2015)
CONSENT TO CRIMINAL OFFENDER
RECORD INFORMATION CHECK
Trial Court of Massachusetts
Juvenile Court Department
I hereby authorize the Juvenile Court to conduct a criminal offender record information check to
determine whether I have a criminal record. I understand the criminal offender record information
check is intended for use by the Court in conjunction with my application for fee generating
appointments. I further understand that the Court will not process my application without
conducting a criminal offender record information check. Therefore, the information below is
willingly supplied by me, and my signature indicates my permission for this record check to be
completed.
Applicant's Name:
Current Address:
Social Security No:
Gender: Male Female Date of Birth:
Place of Birth:
Maiden Name (if applicable):
Other Names or Aliases used:
Mother's Name:
Father's Name:
Date:
(Applicant's Signature)
NOTARIZATION
On this day of , 20 , before me, the undersigned Notary Public,
personally appeared (name of applicant),
proved to me through satisfactory evidence of identification, which were
, to be the person whose name is signed above on
this document in my presence.
(official signature and seal of Notary)
FOR OFFICE USE ONLY
Results of CORI: CORI Check Conducted on:
Record (attached)
No Record
Sealed Record
Date:
(Signature)
