Laserfiche WebLink
THE COMMONWEALTH OF MASSACHUSETTS <br /> EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY <br /> nn��r+ <br /> Department of Criminal Justice Information Services <br /> DUS 200 Ash' p Street,SA 2200,Chelsea,MA 02150 ' <br /> k" %LAW TEL 61)•660.46401 TTY;611046061 FAX;611.6604813 <br /> MARGOVICA <br /> Criminal Offender Record Information [CORI] <br /> Acknowledgement Form <br /> -To be used by 91011816es ronducting CORI chr cks for employment,volunteer,subcontractor,licenslu&and housing <br /> , <br /> purposes „ <, <br /> Comm of Mass ABCC is registered under the <br /> (Organization) <br /> provisions of M.51 c.61 172 to receive CORI for the purpose of screening current and otherwise qualified prospective <br /> employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of <br /> housing, <br /> As a prospective or current employee, subcontractor,volunteer, license applicant, current licensee, or applicant for the <br /> rental or lease of housing, l understand that a CORI check will be submitted for my personal information to the DCIS. I <br /> hereby acknowledge and provide permission to Comm of Mass ABCC <br /> (Organization) <br /> to submit a CORI check for my Information to the DOLS, This authorization Is valid for one year from the date of my <br /> signature, I may withdraw this authorization at any time by providing Comm of Mass ABCC <br /> (Organization) <br /> with written notice of my intent to withdraw consent to a CORI check, <br /> FOR EMPLOYMENT,VOLUNTEER,AND LICENSING PURPOSES ONLY, <br /> The Comm of Mass ABCC may conduct <br /> (Organization) <br /> subsequent CORI checks within one year of the date this Form was signed by me, provided, however,that <br /> Comm of Mass ABCC _ must first provide me <br /> (Organization) <br /> with written notice of this check. <br /> By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of this <br /> Acknowledgement Form is true and accurate. <br /> Mat 11� <br /> gnatureof CORI Sublect Date <br /> 1 <br />