200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973

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

(Organization) 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, 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, 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 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 

with written notice of my intent to withdraw consent to a CORI check.

FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:

(Organization) may conduct subsequent CORI checks within one year of the date this Form was signed by me, provided, however, that 

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.

ONLY FOR CAMP STAFF - If you are working or volunteering at a Spirit of Adventure camp, please tell us what camp or camps.

This form is required by the Commonwealth of Massachusetts. It must be completed and turned into the Council Office in order for the final processing to occur. Thank you!

200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973

Please complete this section using the information of the person whose CORI you are requesting.

The fields marked with an asterisk (*) are required fields.

The following CLEARLY LEGIBLE GOVERNMENT ISSUED PHOTO ID is ATTACHED:

This form is required by the Commonwealth of Massachusetts. It must be completed and turned into the Council Office in order for the final processing to occur. Thank you!