CRIMINAL OFFENDER RECORD INFORMATION (CORI)ACKNOWLEDGEMENT FORM

CRIMINAL OFFENDER RECORD INFORMATION (CORI)ACKNOWLEDGEMENT FORM

Hampden Charter School of Science
TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT, VOLUNTEER, SUBCONTRACTOR, LICENSING AND HOUSING PURPOSES
Hampden Charter School of Science is registered under the provisions of M.G.L. c.6, § 172 to receive CORIs for the purpose of screening current and otherwise qualified 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, the 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 Department of Criminal Justice Information Services (DCJIS).
I hereby acknowledge and provide permission to Hampden Charter School of Science 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 Hampden Charter School of Science with written notice of my intent to withdraw consent to a CORI check.

FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY: The Hampden Charter School of Science may conduct subsequently CORI checks within one year of the date of this form was signed by me provided, however, that Hampden Charter School of Science must first provide me with written notice of this check.

By signing below, I provide my consent to a CORI check and acknowledge that the information provided on the back of this Acknowledgement Form is true and accurate.
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Select School
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Purpose of CORI Request Form*

Employment ApplicationVolunteer/InternStudentSubcontractorClassroom Observation
If Classroom Observation, Name of the Instructor
Maiden Name (or name(s) by which you have been known*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Place of Birth*
Last six digits of your social security number:*
Sex*
Height*
ft
Height*
in
Eye Color*
Race (optional)
Mother's Full Name*
Father's Full Name*
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Former Address*

Street Address

Street Address Line 2

CityState

Zip Code
Driver's License or ID Number*
State of Issue*
If No Driver's License other form of Photo ID #
PLEASE ATTACH A COPY OF YOUR DRIVER'S LICENSE OR PHOTO ID TO VALIDATE IDENTIFICATION*

Cancelof
Should be Empty: