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

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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 

Other (specify):

ID VERIFIED BY:

SUBMITTED TO DCJIS BY:

Name of Verifying Employee (Please print)

Name of authorized employee (Please print)

Signature of Verifying Employee

Signature of Verifying Employee

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CORI Acknowledgment Form.pdf

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