Criminal Offender Record Information (Cori) Acknowledgement Form printable pdf download

NEWTON PUBLIC SCHOOLS

Criminal Offender Record Information (CORI) Acknowledgement Form

TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT,

VOLUNTEER, SUBCONTRACTOR, LICENSING, AND HOUSING PURPOSES

City of Newton – Newton Public Schools (NPS) 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 NPS 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 NPS with written notice of my intent to withdraw consent to a CORI check.

FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY: The NPS may conduct subsequent CORI

checks within one year of the date this Form was signed by me provided, however, that NPS 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 below this

Acknowledgement Form is true and accurate.

_____________________________________________

__________________________________

SIGNATURE

DATE

SUBJECT INFORMATION

* Please be aware that if any information is incomplete this CORI can not be processed.

School/Location:

Specify: Present or Desired Position with NPS

Volunteer (Yes or No)

Name:

First

Middle

Last

Suffix

Maiden Name (or other name(s) by which you have been known):

Date of Birth:

Place of Birth:

Social Security No.

Gender:

Race:

Eye Color

Height: _______ ft. _______ in.

Father’s name:

Last:

First:

Mother’s Name:

Last:

First:

Maiden:

Current Address: No. & Name, City/Town, State Zip:

Former Address: No. & Name, City/Town, State Zip:

Driver’s License or ID Number:

Telephone #

State of Issue:

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

The above information was verified by reviewing the following form(s) of government issued identification

(attached): ____________________________________________________

VERIFIED BY:

Name of NPS Verifying Employee (Please Print)

Signature of Verifying Employee

9/11/13

Criminal Offender Record Information (Cori) Acknowledgement Form

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