DOR_ATT_E_CORI.doc

DOC document 23 KB Posted

Attached to
MASSTAX2 Legal Counsel
Solicitation number
S110391-vCurrent
Issued by
Suffolk County, Boston City, Chelsea City, Massachusetts

About this file

This document is a sample CORI (Criminal Offender Record Information) request form for the Massachusetts Department of Revenue (DOR). The form outlines the process for conducting a criminal record check on applicants/employees of an unspecified organization. The form requires the applicant/employee to provide personal information such as their name, date of birth, social security number, and former addresses. The form also requires the CORI authorized employee to verify the applicant/employee's government-issued photographic identification. The purpose of this CORI request is to obtain conviction and pending criminal case information, which may impact the applicant/employee's eligibility for the position.

The form does not provide any additional details regarding a state or local contract opportunity, such as the products or services requested, project overviews, item quantities, response dates, due dates, site visits, bidder's meetings and conferences, award dates, or the term of the contract including any renewal options. Additionally, the document does not contain any information regarding pricing terms, set asides, incumbents, current environment, funding requirements and sources, or any other salient details related to a contract opportunity.

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Text version

ATTACHMENT E (SAMPLE)

CORI REQUEST FORM

DORMA G

The Massachusetts Department of Revenue (DOR) has been certified by the Criminal History Systems Board for access to conviction and pending criminal case data. As an applicant/employee for __________________________, I understand that a criminal record check will be conducted for conviction and pending criminal case information only and that it will not necessarily disqualify me. The information below is correct to the best of my knowledge.

APPLICANT/EMPLOYEE SIGNATURE

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 MOTHER’S MAIDEN NAME

(Requested but not required)

FORMER ADDRESSES:________________________________________________________________

SEX: _________ HEIGHT: ___ ft. ___ in. WEIGHT: ___________ EYE COLOR: _______

STATE DRIVER’S LICENSE NUMBER: ___________________________________________

*** THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE

FOLLOWING FORM OF GOVERNMENT ISSUED PHOTOGRAPHIC

IDENTIFICATION:___________________________________________________________

REQUESTED BY: ______________________________________________________

SIGNATURE OF CORI AUTHORIZED EMPLOYEE

File details come from the government source that posted it. Updated .