Fill - Free fillable commonwealth of massachusetts CORI Acknowledgement Form cra PDF 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



1



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

AcknowledgementForm



TobeusedbyorganizationsconductingCORIchecksforemployment,volunteer,subcontractor,licensing,andhousing

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prospectiv e

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

housing.



Asaprospectiveorcurrentemployee,subcontractor,volunteer,license

applicant,currentlicensee,orapplicantforthe

rentalorlease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__________________________________________________________

 (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.



FOREMPLOYMENT,VOLUNTEER,ANDLICENSINGPURPOSESONLY:



The_______________________________________________________________________________mayconduct

 (Organization)

subsequentCORI

checkswithinoneyearofthedatethisFormwassignedbyme,provided,however,that

_______________________________________________________________________________,mustfirstprovideme

 (Organization)

withwrittennoticeofthischeck.



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CORISubject Date





Town of Greenfield

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identifica tion:

__________________________________________________________________________________________________



Verifiedby:



___________________________________________________________

 PrintNameofVerifyingEmployee 



___________________________________________________________ _________________________________

 SignatureofVerifyingEmployee Date

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