CORI Acknowledgment Form

Thisformisnottobefaxed.Pleasereturnformtoorganization.

CriminalOffenderRecordInformation(CORI) AcknowledgementForm

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MDPHCORIAcknowledgementFormMarch2018/CORI

(Organization)

isregisteredunderthe

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MDPHCORIAcknowledgementFormMarch2018/CORI

provisionsofM.G.L.c.6,§172toreceiveCORIforthepurposeofscreeningcurrentandotherwisequalifiedprospective employees,subcontractors,volunteers,licenseapplicants,orcurrentlicensees.

Asa prospectiveorcurrent employee,subcontractor,volunteer,licenseapplicantorcurrent licensee,Iunderstandthata CORIcheckwill besubmittedfor mypersonalinformationtotheDCJIS. I herebyacknowledgeandprovidepermission to

tosubmitaCORIcheckfor

myinformationtotheDCJIS.Thisauthorizationisvalidforoneyearfromthedateofmysignature.Imaywithdraw
thisauthorizationatanytimebyproviding

withwrittennoticeofmyintenttowithdrawconsenttoaCORIcheck.

Ialsounderstand,that

mayconductsubsequentCORIcheckswithinoneyearofthedatethisFormwassignedbyme.

Bysigningbelow,IprovidemyconsenttoaCORIcheckandaffirmthattheinformationprovidedonPage2ofthis AcknowledgementFormistrueandaccurate.

SignatureofCORISubjectDate

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MDPHCORIAcknowledgementFormMarch2018/CORI

SUBJECTINFORMATION

Please completethis sectionusingthe informationof the personwhoseCORIyouare requesting.

The fieldsmarkedwith anasterisk(*)arerequiredfields.

*FirstName:MiddleInitial:

*LastName:Suffix(Jr.,Sr.,etc.):

FormerLastName1:

FormerLastName2:

FormerLastName3:

FormerLastName4:

*DateofBirth (MM/DD/YYYY):PlaceofBirth:

*LastSIXdigitsofSocialSecurityNumber:‐‐□NoSocialSecurityNumber

Sex:Height:ft.in.EyeColor:Race:

Driver’sLicenseorIDNumber:StateofIssue:

Father’sFullName:

Mother’sFullName:

CurrentAddress

*StreetAddress:

Apt.#orSuite:*City:*State:*Zip:

SUBJECTVERIFICATION

Theaboveinformationwasverifiedbyreviewingthefollowingform(s)ofgovernment‐issuedidentification:

Verifiedby:

PrintNameofVerifyingEmployee

SignatureofVerifyingEmployeeDate

AuthenticationofSignature

PleasenotethatALLfieldsinthissectionmustbecompletedbythe NotaryPublic.

Onthisdayof_,20,beforeme,theundersignedNotaryPublic,personallyappeared

(nameofCORIrequestor)andprovedtomethroughsatisfactory evidenceofidentification,whichwas (Ex:Driver’slicense,passport,etc.),tobetheperson whosenameissignedontheprecedingorattacheddocument,andacknowledgedtomethat(he)(she)signedit voluntarilyforitsstatedpurpose.

SignatureofNotaryPublic(Notarystampor sealisalsorequired) DatemyCommissionexpires

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MDPHCORIAcknowledgementFormMarch2018/CORI