South Shore Regional School District 476 Webster Street Hanover, Massachusetts 02339-1215 781.878.8822
CRIMINAL OFFENDER RECORD INFORMATION (CORI) ACKNOWLEDGEMENT FORM
South Shore Regional School District 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, and volunteers. As a prospective or current employee, subcontractor, or volunteer, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to South Shore Regional School District 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 South Shore Regional School District with written notice of my intent to withdraw consent to a CORI check. The South Shore Regional School District may conduct subsequent CORI checks within one year of the date this Form was signed by me provided, however, that South Shore Regional School District 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 herein is true and accurate.
Signature
Date
over
Please complete the entire application. Your current picture ID MUST be attached to this form. Position applied for: (e.g. Employee, Student Teacher, Volunteer, Contractor) If you are applying to chaperone a field trip, please indicate destination/date:
Last Name
First Name
Middle Initial
(Maiden name, if any)
___ ____- ___ ___ - ___ ___ ___ ___ Date of Birth (MM-DD-YYYY)
Gender: M / F
Place of Birth (City, State, Country)
Height:
ft.
in.
Last Six (6) Digits of Your Social Security Number: Driver’s License or ID Number:
Eye color:__________
Race:
State of Issue:
/ Mother’s Full Name (First, Middle, Last / Maiden)
Father’s Full Name (First, Middle, Last)
Current Street Address Street Address
City/Town
State
Zip
Street or P.O. Box No.
City/Town
State
Zip
City/Town
State
Zip
Mailing Address (if different) Former Address(es) (If less than 5 years at current)Street Address
FOR OFFICE USE ONLY: The above information was verified by review of the following form of valid, government-issued photographic identification: Massachusetts Driver’s License
*Date of Birth Place of Birth. * Last Six Digits of Your Social Security Number: ______-______ (REQUIRED). Sex: ____ Height: ___ft. __ in. Eye Color: ______ Race: ______. Driver's License or ID Number: ...
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understand that a CORI check will be submitted for my personal information to the Department of. Criminal Justice Information Services (DCJIS). I hereby ...
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There was a problem loading more pages. Whoops! There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. CORI Form--UPDATED June 1, 2012 & Updated July 23, 2014.pdf.