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

To be used by organizations conducting CORI checks for employment or licensing 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 prospective employees, subcontractors, volunteers, license applicants, current licensees.

As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, 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.

I also understand, that may conduct

(Organization)

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

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

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

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