criminal offender record information (cori) acknowledgement form

CRIMINAL OFFENDER RECORD INFORMATION (CORI)

ACKNOWLEDGEMENT FORM

TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT, VOLUNTEER,

SUBCONTRACTOR, LICENSING, AND HOUSING PURPOSES.

e Oce of the Secretary of the Commonwealth, Securities Division is registered under the

provisions of MASS. GEN. LAWS c. 6, § 172 to receive CORI for the purpose of screening

current and otherwise qualied prospective 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 Massachusetts DCJIS (“Department of

Criminal Justice Information Services”). I hereby acknowledge and provide permission to the

Oce of the Secretary of the Commonwealth, Securities Division to submit a CORI check

for my information to the DCJIS. is authorization is valid for one (1) year from the date

of my signature. I may withdraw this authorization at any time by providing the Oce of the

Secretary of the Commonwealth, Securities Division written notice of my intent to withdraw

consent to a CORI check.

FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:

e Oce of the Secretary of the Commonwealth, Securities Division may conduct subse-

quent CORI checks within one (1) year of the date this Form was signed by me provided,

however, that e Oce of the Secretary of the Commonwealth, Securities Division must rst

provide me with written notice of this check.

By signing below, I provide my consent to a CORI check and acknowledge that the informa-

tion provided on Page 2 of this Acknowledgement Form is true and accurate.

Signature Date

PURSUANT TO DCJIS REQUIREMENTS, THE SIGNATURE ABOVE MUST BE NOTA-

RIZED BEFORE THIS FORM IS SENT IN ELECTRONIC FORMAT TO THE OFFICE OF

THE SECRETARY OF THE COMMONWEALTH, SECURITIES DIVISION.

Page 1 of 2

SUBJECT INFORMATION: (A red asterisk (*) denotes a required eld)

* Last Name * First Name Middle Name Sux

Maiden Name (or other name(s) by which you have been known)

Former Last Name 1:

Former Last Name 2:

Former Last Name 3:

Former Last Name 4:

* Date of Birth: Place of Birth:

* Last Six Digits of Your Social Security Number: -

Sex: Height: ft. in. Eye Color: Race:

Driver’s License or ID Number: State of Issue:

Mother’s Full Maiden Name Father’s Full Name

Current and Former Addresses:

Street Number & Name City/Town State Zip

e above information was veried by reviewing the following form(s) of government-issued

identication:

Veried by:

Name of Verifying Employee (Please Print) Signature of Verifying Employee

Page 2 of 2