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CRIMINAL OFFENDER RECORD INFORMATION (CORI) ACKNOWLEDGEMENT FORM

TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT, VOLUNTEER,
SUBCONTRACTOR, LICENSING, AND HOUSING PURPOSES.

The Office of the Secretary of the Commonwealth, Securities Division is registered under the
provisions of MASS. GEN. LAWS c. 6, § 172 to receive CORI for the purpose of screening
current and otherwise qualified prospective employees, subcontractors, volunteers, license
applicants, current licensees, and applicants for the rental or lease of housing.

As a prospective or current employee, subcontractor, volunteer, license applicant, current
licensee, or applicant for the rental or lease of housing, I understand that a CORI check will
be submitted for my personal information to the Massachusetts DCJIS (“Department of
Criminal Justice Information Services”). I hereby acknowledge and provide permission to the
Office of the Secretary of the Commonwealth, Securities Division to submit a CORI check
for my information to the DCJIS. This authorization is valid for one (1) year from the date
of my signature. I may withdraw this authorization at any time by providing the Office of the
Secretary of the Commonwealth, Securities Division written notice of my intent to withdraw
consent to a CORI check.

FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:

The Office of the Secretary of the Commonwealth, Securities Division may conduct subsequent CORI checks within one (1) year of the date this Form was signed by me provided, however, that The Office of the Secretary of the Commonwealth, Securities Division must first
provide me with written notice of this check.

SUBJECT INFORMATION: (An asterisk (*) denotes a required field)

Last Name*:

First Name*:

Middle Name:

Suffix:

Maiden Name (or other name(s) by which you have been known):

Date of Birth*: Date of Birth:

Place of Birth:

Last Six Digits of Your Social Security Number*:

Sex:

Height:

ft. in.

Eye color:

Race:

Driver’s License or ID Number:

State of Issue:

Mother’s Full Maiden Name:

Father’s Full Name:

Current and Former Addresses:

Street Number & Name City/Town State Zip

By signing below, I provide my consent to a CORI check and acknowledge that the information provided on this Acknowledgement Form is true and accurate.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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April 7, 2023 7:11 pm EDT

CRIMINAL OFFENDER RECORD INFORMATION (CORI) ACKNOWLEDGEMENT FORM Uploaded by Devin Ulibarri - devin@remakemusic.net IP 185.220.101.130