Criminal Offender Record Information (Cori) Acknowledgement Form
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1
2Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
Division of Health Care Facility Licensure and Certification
99 Chauncy Street, 11th floor, Boston, MA 02111
617-753-8000
Criminal Offender Record Information (CORI) Acknowledgement Form
The Department of Public Health, Division of Health Care Facility Licensure and Certification, is certified by the
Department of Criminal Justice Information Services (DCJIS) to screen applicants for licenses to operate health
care facilities and programs. As a licensure applicant, I understand that a CORI check will be submitted to DCJIS
for my personal information. I understand that a criminal offender record information (CORI) check will be
conducted for conviction and pending criminal case information, only, and that such information will not
necessarily disqualify me. The information below is correct to the best of my knowledge. I hereby acknowledge
and provide permission to submit a CORI check for my information to the DCJIS.
Signature
Date
*Last Name
*First Name
Middle Name
Suffix
Maiden Name (or other name(s) by which you have been known)
XXX /
/
*Date of Birth, mm/dd/yyyy
Place of Birth
*Last Six Digits of Your Social Security Number
Sex
M
F
Height
Eye Color
Race
ft
in
Driver's License or ID Number
State of Issue
Mother's Full Maiden Name
Father's Full Name
Current Address
Street Number & Name
City/Town
State
Zip
Former Address
Street Number & Name
City/Town
State
Zip
DPH/DHCFLC use only.
The above information was verified by reviewing the following form(s) of government-issued
identification:
Name of Verifying Employee (Please Print)
Signature of Verifying Employee
DPHCQ CORI Form May 2012
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