CORI_BACKGROUND_CHECK.pdf
PDF 145 KB Posted
- Solicitation number
- BD-16-1016-CM1JC-CM1JC-00000008829
- Issued by
- Suffolk County, Massachusetts
About this file
This document is a background information request and waiver form from the Commonwealth of Massachusetts Executive Office of Public Safety and Security Office of the Chief Medical Examiner. The form is used to conduct a background investigation, including a criminal records check, for new employees, contract employees, or other applicants for a position. The investigation may include checks with former employers, local police, the state police, the Massachusetts Board of Probation, and the Registry of Motor Vehicles, as well as interviews with character references.
The related state and local contract opportunity is for RFR# OCME2016-003 Cremation Examination and Authorization, issued by the Commonwealth of Massachusetts. No other details about the scope, quantities, response dates, award dates, or contract term are provided in the document.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| CASL_VERIFICATIONS.pdf | ||
| RFR_OCME2016-003_SCOPEOFSERVICE.pdf | ||
| OCME_2016-003_CONTRACT.pdf | ||
| NEWMASS_W9.pdf | ||
| EFT_FORM~1.pdf | ||
| TERMS_CONDITIONS.pdf | ||
| RFR_OCME2016-003~1.pdf |
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Text version
The Commonwealth of Massachusetts
Executive Office of Public Safety and Security Office of the Chief Medical Examiner
Headquarters
720 Albany Street
Boston, MA 02118-2518
BACKGROUND INFORMATION REQUEST AND WAIVER
{Please print clearly or type)
NEW EMPLOYEE________ CONTRACT EMPLOYEE________ OTHER______ __
TITLE OF POSITION APPLYING FOR:
PERSONAL DATA:
NAME:
Last First Middle
SOCIAL SECURITY#: / / _
DRIVER'S LICENSE#:
DATE OF BIRTH: / / PLACE OF BIRTH: SEX: RACE
PREVIOUS NAME(S) AND/OR ALIAS:
RESIDENTIAL ADDRESS:
(NO P.O. BOXES ACCEPTED) Number Street City/State Zip
IF YOU HAVE EVER RESIDED IN ANY OTHER STATE(S) PLEASE LIST ALL BELOW
I, __________________________, hereby release, discharge, and exonerate the Office of the Chief Medical Examiner, its agents and representatives, and any person so furnishing information, for any and all liability of every nature and kind arising out of the furnishing or inspection of such documents, records and other information or investigations made by or on behalf of the Office of the Chief Medical Examiner.
I further understand that the Office of the Chief Examiner may conduct a background investigation which will include a check with any former employers, a criminal records check with the local police department, the state police, the Massachusetts Board of Probation, the Registry of Motor Vehicles and interviews with my character references.
SIGNATURE: DATE: _
Henry M. Nields, MD, PhD Chief Medical Examiner
General Office Numbers
Tel: (617) 267-6767 Tel: (800) 962-7877 Fax: (617) 266-6763
Charles D. Baker Governor
Karyn E. Polito
Lieutenant Governor
Daniel Bennett Secretary
File details come from the government source that posted it. Updated .