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Criminal Offender Record Information

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Employment Application
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Criminal Offender Record Information
Department of Criminal
Justice
Employment Eligibility Verification

THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

Arlington Street, Suite 2200, Chelsea | MA 02150, TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973 | MASS.GOV/CJIS

Criminal Offender Record Information (CORI) Acknowledgement Form

is registered under the (Organization) provisions of M.G.L. c.6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, or current licensees.
As a prospective or current employee, subcontractor, volunteer, license applicant or current licensee, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to
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
with written notice of my intent to withdraw consent to a CORI check.
I also understand, that
may conduct subsequent CORI checks within one year of the date this Form was signed by me.
By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of this Acknowledgement Form is true and accurate.
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