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

Criminal Offender Record Information (Cori) Acknowledgement Form

COMMONWEALTH OF MASSACHUSETTS

BOARD OF PUBLIC ACCOUNTANCY

1000 Washington Street, Suite 710

Boston, MA 02118-6100

CRIMINAL OFFENDER RECORD INFORMATION (CORI)

ACKNOWLEDGEMENT FORM

The Division of Professional Licensure by itself and on behalf of boards of registration pursuant to

M.G.L. c. 13, §9 [hereinafter, “Division of Professional Licensure”] 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 license applicants

and current licensees.

As a license applicant or current licensee, 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 the Division of Professional Licensure 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 the Division of Professional Licensure written notice of my intent to withdraw consent to a

CORI check.

FOR LICENSING PURPOSES ONLY:

The Division of Professional Licensure may conduct subsequent CORI checks within one year of the date this Form

was signed by me. If subsequent CORI checks are necessary, the Division of Professional Licensure will provide me

with written notice of the subsequent CORI checks.

By signing below, I provide my consent to a CORI check and acknowledge that the information provided on Page 2

of this Acknowledgement Form is true and accurate.

_________________________________

Signature

Date

Please provide the name of the board of registration and license type for which you are applying or currently hold:

_________________________________

Board of Registration

License Type

NOTE: DPL CANNOT ACCEPT THIS TWO-PAGE CORI ACKNOWLEDGMENT FORM UNLESS IT IS

EITHER (1) SIGNED IN PERSON AT THE BOARD'S OFFICES IN THE PRESENCE OF A DPL EMPLOYEE

WHO HAS VERIFIED THE APPLICANT'S IDENTITY THROUGH ACCEPTABLE IDENTIFICATION, OR (2)

SIGNED IN THE PRESENCE OF A NOTARY PUBLIC WHO HAS LIKEWISE VERIFIED IDENTITY AND

THEN MAILED OR OTHERWISE DELIVERED TO THE BOARD'S OFFICES AT THE ADDRESS SET FORTH

ABOVE.

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Criminal Offender Record Information (Cori) Acknowledgement Form