NORTH ANDOVER PUBLIC SCHOOLS Jennifer Price, Ed.D. Superintendent

Administration Offices 566 Main St. North Andover, MA 01845 Telephone 978 794-1503 Fax 978 794-0231

Gregg Gilligan Assistant Superintendent

CRIMINAL OFFENDER RECORD INFORMATION (CORI) ACKNOWLEDGEMENT FORM TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT, VOLUNTEER AND SUBCONTRACTOR PURPOSES. The North Andover Public Schools 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, volunteers and subcontractors. 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 the North Andover Public Schools 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 written notice of my intent to withdraw consent to a CORI check. FOR EMPLOYMENT AND VOLUNTEER PURPOSES ONLY: The North Andover Public Schools may conduct subsequent CORI checks within one year of the date this Form was signed by me provided, however, that the North Andover Public Schools 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 on Page 2 of this Acknowledgement Form is true and accurate. SIGNATURE:______________________________ PLEASE CHECK OFF: Employee

DATE:_________________________

Volunteer

Subcontractor

Student

If a volunteer, please provide child’s name_________________________________________ If a volunteer, please initial below acknowledging that you have been provided with, read, understand, and agree to comply with School Committee Policy IJOC-E INITIAL:_____________

CORI forms mailed in WILL NOT be processed. ID’s need to be verified and photocopied by authorized school personnel.

OTHER SIDE MUST BE COMPLETED 1 OF 2

SUBJECT INFORMATION: ___________________________________________________________________________ *Last Name *First Name Middle Name Suffix __________________________________________________ Maiden Name (or other name(s) by which you have been known) _______________________________ *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: _____________________ State of Issue:___________ ____________________________________ Mother’s Full Maiden Name

_______________________________ Father’s Full Name

Phone number:_______________________________ Current and Former Addresses: ___________________________________________________________________________ Street Number & Name City/Town State Zip ___________________________________________________________________________ Street Number & Name City/Town State Zip __________________________________________________________________________ The above information was verified by reviewing the following form(s) of government-issued identification: _______________________________________________________ (i.e. – driver’s license, passport, state issued identification card with photograph or military identification) BELOW IS TO BE COMPLETED BY SCHOOL PERSONNEL: VERIFIED BY: ___________________________________________________________ Name of Verifying Employee (Please Print) /School Name ________________________________________________ Signature of Verifying Employee

COPY OF ID MUST BE ATTACHED IN ORDER TO PROCESS CORI FORM Please write legibly so form can be processed. CORI form will NOT be processed if pages 1 & 2 are not complete. Please Note: A CORI Form is valid for 3 yrs. 2 OF 2