newCori.doc
DOC document 58 KB Posted
- Attached to
- Interviewer/Raters for Sign Language Proficiency Interview (SLPI) Assessment Instrument - Multiple P
- Solicitation number
- S110505-vCurrent
- Issued by
- Suffolk County, Massachusetts
About this file
This document is a Criminal Offender Record Information (CORI) request form from the Executive Office of Health and Human Services (EOHHD) in Massachusetts. The purpose of this form is to conduct a criminal background check on an applicant or contract employee. The form requests personal information such as name, date of birth, social security number, driver's license number, and previous addresses. The form must be signed by the applicant and reviewed by an authorized CORI employee. This CORI check will be used to evaluate the applicant's suitability for employment or a contract position, though the information will not necessarily disqualify the applicant.
The document does not contain any details about a state or local contract opportunity. It is solely focused on the CORI request process for an individual applicant or employee.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| RFR_0805MCD_SLPI_Evaluators.doc | DOC document | |
| S110505-vCurrent_OD.xlsx | XLSX spreadsheet | |
| c_tc.doc | DOC document | |
| EFT_form.doc | DOC document | |
| Mass_W_9.DOC | DOC document | |
| RFR_0805MCD_SLPI_Evaluators_AMENDMENT.docx | DOCX document | |
| standard_contract_frm-2.doc | DOC document | |
| consig.doc | DOC document |
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Text version
EOHHD
CORI REQUEST FORM
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/contract employee, 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 SIGNATURE
DATE
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
DATE
_1182764137.doc
Mitt Romney
Governor
Kerry Healey
Lieutenant Governor
Timothy R. Murphy
Secretary
Heidi L. Reed
Commissioner
150 Mount Vernon Street
Suite 550
Boston, MA 02125
The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Massachusetts Commission for the
Deaf and Hard of Hearing http://www.mass.gov/mcdhh
(617) 740-1600 Voice
(617) 740-1700 TTY
(800) 882-1155 Voice
(800) 530-7570 TTY
(617) 740-1880 Fax
File details come from the government source that posted it. Updated .