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THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY Department of Criminal Justice Information Services 200 Arlington Street, Suite 2200, Chelsea, MA 02150 TEL: [PHONE REDACTED] I TTY: [PHONE REDACTED] I FAX: [PHONE REDACTED] MASS.GOV/CJIS 1 Criminal Offender Record Information (CORI) Acknowledgement Form To be used by organizations conducting CORI checks for employment, volunteer, subcontractor, licensing, and housing purposes. is registered under the (Organization) 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 (Organization) with written notice of my intent to withdraw consent to a CORI check. FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY: The may conduct (Organization) subsequent CORI checks within one year of the date this Form was signed by me, provided, however, that must first provide me (Organization) 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. Signature of CORI Subject Date THE CITY OF SALEM THE CITY OF SALEM THE CITY OF SALEM THE CITY OF SALEM THE CITY OF SALEM ---PAGE BREAK--- THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY Department of Criminal Justice Information Services 200 Arlington Street, Suite 2200, Chelsea, MA 02150 TEL: [PHONE REDACTED] I TTY: [PHONE REDACTED] I FAX: [PHONE REDACTED] MASS.GOV/CJIS 2 SUBJECT INFORMATION Please complete this section using the information of the person whose CORI you are requesting. The fields marked with an asterisk are required fields. * First Name: Middle Initial: * Last Suffix (Jr., Sr., etc.): Former Last Name 1: Former Last Name 2: Former Last Name 3: Former Last Name 4: * Date of Birth (MM/DD/YYYY): Place of Birth: * Last SIX digits of Social Security Number: ☐ No Social Security Number Sex: Height: ft. in. Eye Color: Race: Driver’s License or ID Number: State of Issue: Father’s Full Name: Mother’s Full Name: Current Address * Street Address: Apt. # or Suite: *City: *State: *Zip: SUBJECT VERIFICATION The above information was verified by reviewing the following form(s) of government‐issued identification: Verified by: Print Name of Verifying Employee Signature of Verifying Employee Date