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
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Criminal Offender Record Information (CORI) Acknowledgement Form
To be used by organizations conducting CORI checks for employment or licensing purposes.

Community Access Inc. 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, or current licensees.

As a prospective or current employee, subcontractor, volunteer, license applicant or 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 Community Access Inc.

(Organization) to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my Community Access Inc. signature. I may withdraw this authorization at any time by providing

with written notice of my intent to withdraw consent to a CORI check.
Community Access (Organization) may conduct 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

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Date

MonthDayYear
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.
Name

First NameMiddle InitialLast NameSuffix (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):

MonthDayYear
Date
Place of Birth:
Social Security Number:

No Social Security Number
Social Security Number:
Sex:
Height: feet
inches
Eye Color:
Race:
Driver's License or ID Number:
State of Issue:
Father'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:
Print Name of Verifying Employee
Signature of Verifying Employee

Clear
Date

MonthDayYear
Date
Should be Empty:

THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

7Kis IRUP is QRW WR EH ID[HG 3OHDsH UHWXUQ IRUP WR RUJDQi]DWiRQ

Criminal Offender Record Information (CORI) Acknowledgement Form

THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

SUBJECT INFORMATION

Current Address

SUBJECT VERIFICATION

7Kis IRUP is QRW WR EH ID[HG 3OHDsH UHWXUQ IRUP WR RUJDQi]DWiRQ