2016 Version EHS DCS CORI Form 07 2015~1.pdf

NOTICE TO FINAL CANDIDATES

In the event that a CORI investigation returns a record with a criminal history that is relevant to the duties of the position being sought, the CORI results may be utilized by a qualified mental health professional in order to make a determination regarding whether or not the candidate poses an unacceptable risk of harm to the clients of the agency, in accordance with 101 DMR 15.09.

AGENCY CODE: EOHHD

FEE CODE:

The Executive Office of Health and Human Services has been certified by the Criminal History Systems Board for access to conviction and pending criminal case data. As an applicant/employee for the position of , I understand that a criminal offender record information (CORI) check will be conducted for conviction and pending criminal case information only and that such information will not necessarily disqualify me. The information below is correct to the best of my knowledge.

APPLICANT/EMPLOYEE SIGNATURE

(Unless otherwise preempted by law)

APPLICANT/EMPLOYEE INFORMATION (PLEASE PRINT)

LAST NAME FIRST NAME MIDDLE NAME

MAIDEN NAME OR ALIAS (IF APPLICABLE) PLACE OF BIRTH

DATE OF BIRTH SOCIAL SECURITY NUMBER ID Theft Index PIN (if applicable)*

MOTHER’S MAIDEN NAME

CURRENT AND FORMER ADDRESSES:

SEX: HEIGHT: ft. in. WEIGHT: EYE COLOR:

STATE DRIVER’S LICENSE NUMBER:

(include state of issue)

THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE FOLLOWING FORM OF GOVERNMENT

ISSUED PHOTOGRAPHIC IDENTIFICATION:

(Attach COPY of PHOTO ID)

REVIEWED BY:

Signature-SUPERVISOR/MANAGER REVIEWING IDENTIFICATION

REQUESTED BY:

SIGNATURE OF CORI AUTHORIZED EMPLOYEE

*The CHSB Identity Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft PIN Number by the CHSB. Certified agencies are required to provide all applicants the opportunity to include this information to ensure the accuracy of the CORI request process. All CORI request forms that include this field are required to be submitted to the CHSB via mail or by fax to 617-660-4614

CHARLES D. BAKER

Governor

KARYN POLITO

Lieutenant Governor

Commonwealth of Massachusetts Executive Office of Health and Human Services

Disabilities and Community Services Office of Human Resources

600 Washington Street Boston MA 02111

MARYLOU SUDDERS

Secretary

CORI REQUEST FORM