Recreation CORI Request

Town of Ashland, Massachusetts

Recreation Department 162 West Union Street, 01721-1191

(508) 881-0140 x. 2 (508)532-8092(fax)

Criminal Offender Record Information

To be used by organizations conducting CORI checks for employment, volunteer and subcontractor purposes

Ashland Recreation Department is registered under the provisions of M.G.L.c.6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees and subcontractors.

As a prospective or current employee, subcontractor, volunteer, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to Ashland Recreation Department to submit a CORI check for my information to DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at any time by providing the Ashland Recreation Department with written notice of my intent to withdraw consent to a CORI check.

FOR EMPLOYMENT AND VOLUNTEER PURPOSES ONLY:

The Ashland Recreation Department may conduct subsequent CORI checks within one year of the date this form was signed by me, provided however, that Ashland Recreation Department must first provide me 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

Recreation Department 162 West Union Street, 01721-1191

(508) 881-0140 x. 2 (508)532-8092(fax)

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*

Sex M/F

Former Last Name 1

Former Last Name 2

Former Last Name 3

Former Last Name 4

Date of Birth (MMDDYYYY)*

please enter numbers only (no hyphens)

Place of Birth

Race

Last SIX (6) Digits of Social Security Number: XXX - ___ ___ ___ ___ ___ ___*

Please enter numbers only, no hyphens. If no social security number please enter XXXXXX, you will be required to provide additional federal issued documentation.

I do not have a Social Security Number

Select

Father's Last Name*

Father's First Name*

Mother's Last Name*

Mother's First Name*

Mother's Maiden Name*

Street Address*

Apt. # or Suite

City*

State*

Zip Code*

This form requires the submissin of a valid government-issued identification to verify the above information. Your form is not complete until you email Recreation@AshlandMass.com a copy your valid driver's license, passport, military identification, state issued identification card with photograph or Native American Tribal documentation.*

Acknowledged

Town of Ashland, Massachusetts

SUBJECT INFORMATION