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TOWN OF WATERTOWN
PERSONNEL DEPARTMENT
Administration Building, 149 Main Street
Watertown, Massachusetts 02472-4410
Tel. (617) 972-6443 • Fax (617) 923-8195
www.watertown-ma.gov
personnel@watertown-ma.gov
GAYLE M. SHATTUCK
Personnel Director
CRIMINAL OFFENDER RECORD INFORMATION (CORI)
ACKNOWLEDGEMENT FORM
Department and Position Applying for: _____________________________
__________________________________________________________
The Town of Watertown 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, volunteer, 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 DCJIS. I hereby acknowledge and provide
permission to the Town of Watertown 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 the Town of Watertown with written notice of my intent
to withdraw consent to a CORI check.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY: The Town of
Watertown may conduct subsequent CORI checks within one year of the date this Form was
signed by me provided, however, that the Town of Watertown must first provide me with written
notice of this check.
By signing below, I provide my consent to a CORI check and acknowledge that the information
provided on Page 2 of the Acknowledgement Form is true and accurate.
______________________________________ ________________________
SIGNATURE DATE
Page 2
SUBJECT INFORMATION: PRINT CLEARLY
Last Name First Name Middle Name Suffix
Maiden Name (or other name(s) by which you have been known)
______________________________ ____________________________________
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 Code
____________________________________________________________________________
Street Number & Name City/Town State Zip Code
The above information was verified by reviewing the following form(s) of government issued identification:
__________________________________________________
__________________________________________________
VERIFIED BY: _________________________________________________
Please Print
_________________________________________________
Signature of Verifying Employee
August 2014