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Onboarding-Consent-Documents

Criminal Offender Record Information (CORI) Acknowledgement Form

NEEDS Center Inc. (Organization)

is registered under the 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 NEEDS Center Inc. (Organization)

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 NEEDS Center Inc (Organization) with written notice of my intent to withdraw consent to a CORI check.

I also understand, that NEEDS Center Inc (Organization) 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.

THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVEOFFICE 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

This form is not to be faxed. Please return form to organization .

Criminal Offender Record Information(CORI) Acknowledgement Form

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

Name
Name
First Name
Last Name
enter “none” if no middle name
Feet
Inches
Height
Height
Feet
inches

Current Address

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