Department of Criminal Justice

THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

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

SUBJECT INFORMATION

Please complete this section using the information of the person whose CORI you are requesting.
The fields marked with an asterisk (*) are required fields.

First Name

Middle Initial

Last Name

Former Last Name 1

Former Last Name 2

Former Last Name 3

Former Last Name 4

Date of Birth

Place of Birth

Social Security Number

If dont have SSN

No Social Security Number

Sex

Height Feet

Height Inch

Eye Color

Race

Driver’s License or ID Number

State of Issue

Father’s Full Name

Mother’s Full Name

Current Address

Street Address

Apt. # or Suite

City

State

Zip

SUBJECT VERIFICATION

The above information was verified by reviewing the following form(s) of government‐issued identification:

Verified by

Date