CORI Acknowledgement Form_INDIVIDUAL PROVIDERS ONLY.docx

The Commonwealth of Massachusetts Executive Office of Health and Human Services Massachusetts Rehabilitation Commission 600 Washington Street Boston, MA 02111-1704

MAURA HEALEY

GOVERNOR

KIM DRISCOLL

LIEUTENANT GOVERNOR

WILLIAM GALVIN

SECRETARY

TONI WOLF

COMMISSIONER

(617) 204-3600 1 (800) 245-6543 Voice/TDD (617) 204-3665

FAX (617) 727-1354

CRIMINAL OFFENDER RECORD INFORMATION (CORI)

ACKNOWLEDGEMENT FORM

The Massachusetts Rehabilitation Commission 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, contract providers, volunteers, and interns.

As a prospective or current employee, contract provider, volunteer or intern, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to the Massachusetts Rehabilitation Commission 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 the Massachusetts Rehabilitation Commission written notice of my intent to withdraw consent to a CORI check.

The Massachusetts Rehabilitation Commission may conduct subsequent CORI checks within one year of the date this Form was signed by me provided, however, that the Massachusetts Rehabilitation Commission 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 Date

(OVER)

CORI ACKNOWLEDGEMENT FORM (CONT.)

*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: ______________-_______________

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

Current and Former Addresses:

Street Number & Name City/Town State Zip code

________________________________________________________________________Street Number & Name City/Town State Zip code

The above information was verified by reviewing the following form(s) of government issued identification:

VERIFIED BY:_______________________________________

Name of Verifying Employee (Please Print)

Signature of Verifying Employee

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