Criminal Records History Disclosure Form.doc

Do not complete this page unless a hiring state agency requests this information.

Criminal Records History Disclosure Form

Criminal Offender Record Information (C.O.R.I) and Sex Offender Registry Information (S.O.R.I.)

Have you been convicted of a felony? YES FORMCHECKBOX

NO FORMCHECKBOX

Having a conviction may not necessarily automatically disqualify you from consideration. A criminal background check will only occur, and its results will only be considered, in those instances where a prospective employee shall have been deemed otherwise qualified and the content of a criminal record is relevant to the duties and qualifications of the position in question. Such instances will include, without limitation, those in which a criminal conviction creates a statutory disqualification for the position, or the position requires interaction with vulnerable populations and a criminal background check is necessary to ensure that the applicant does not pose a public safety risk.

If yes, please explain.*

Have you been convicted of a misdemeanor other than a first misdemeanor conviction for drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace within the last 5 years? YES FORMCHECKBOX

NO FORMCHECKBOX

(Conviction will not necessarily disqualify an applicant from employment.) If yes, please explain.* ________________________________________________________________________________________________________________________________________

· “An applicant for employment with a sealed record on file with the commissioner of probation may answer ‘no record’ with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. An applicant for employment with a sealed record on file with the commissioner of probation may answer ‘no record’ to an inquiry herein relative to prior arrests or criminal court appearances. In addition, any applicant for employment may answer ‘no record’ with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution.”

MGL Ch. 276, Section 100A.