Fill - Free fillable Massachusetts Criminal Offender Record Information Acknowledgement Form PDF form

1

TobeusedbyorganizationsusingconsumerreportingagenciestoconductCORIchecksforemployment,volunteer,

subcontractor,licensing,andhousingpurposes.

_______________________________________________________________________________isregisteredunderthe

(Organization)

provisionsofM.G.L.c.6,§172toreceiv eCORIforthepurposeofscreeningcurrentandotherwisequalifiedprospective

employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of

housing._______________________________________________________________________________hasauthorized

(Organization)

_______________________________________________________________________________tosubmitCORIchecks

(ConsumerReportingAgency)

totheMassachusettsDepartmentofCriminalJusticeInformationServices(DCJIS)onitsbehalf.

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

rentalorleas eofhousing,IunderstandthataCORIcheckwillbesubmittedformypersonalinformationtotheDCJIS.I

herebyacknowledgeandprovidepermissionto__________________________________________________________

(ConsumerReportingAgency)

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 noti

ce of my intent to withdraw consent to a CORI check. I also understand that this form is a CORI

acknowledgement form and I am entitled to additional consumer reporting disclosure forms under the Fair Credit

ReportingAct.IfIhavenotreceivedthosedisclosures,Ishouldcontact________________________________________

(Organization)

torequestthisinformation.

FOREM

PLOYMENT,VOLUNTEER,ANDLICENSINGPURPOSESONLY:

I also undertand that the

_______________________________________________________________________________,onbehalfof

(ConsumerReporting

Agency)

_______________________________________________________________________________mayconduct

(Organization)

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

By signing below, I provide my conse

nt to a CORI check and affirm that the information provided on Page 2 of this

AcknowledgementFormistrueand accurate. 

___________________________________________________________ _________________________________

SignatureofCORI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Number: ______‐‐____________ ☐NoSocialSecurityNumber



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



 Driver’sLicenseorIDNumber:______________________________________ 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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Massachusetts Criminal Offender Record Information Acknowledgement Form

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