HomeMy Public PortalAboutCORI_201601250948419753Gayle M. Shattuck
Personnel Director
TOWN OF WATERTOWN
Personnel Department
Administration Building
149 Main Street
• Watertown, MA 02472
Phone: 617.972.6443
Fax: 617.923.8195
www.wa to r town•ma. g ov
personnel@watertowruma.gov
CRIMINAL OFFENDER RECORD INFORMATION (CORI)
ACKNOWLEDGEMENT FORM
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 1
SUBJECT INFORMATION:
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
January 2013