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THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE 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

Criminal Offender Record Information (CORI)

Acknowledgement Form

To be used by organizations using consumer reporting agencies to conduct CORI checks for employment, volunteer,

subcontractor, licensing, and housing purposes.

_______________________________________________________________________________ is registered under the

(Organization)

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, current licensees, and applicants for the rental or lease of

housing. _______________________________________________________________________________ has authorized

(Organization)

_______________________________________________________________________________ to submit CORI checks

(Consumer Reporting Agency)

to the Massachusetts Department of Criminal Justice Information Services (DCJIS) on its behalf.

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 __________________________________________________________

(Consumer Reporting Agency)

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 _________________________________________

(Organization)

with written notice of my intent to withdraw consent to a CORI check. I also understand that this form is a CORI

acknowledgement form and I am entitled to additional consumer reporting disclosure forms under the Fair Credit

Reporting Act. If I have not received those disclosures, I should contact ________________________________________

(Organization)

to request this information.

FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:

The _______________________________________________________________________________, on behalf of

(Consumer Reporting Agency)

_______________________________________________________________________________ may conduct

(Organization)

subsequent CORI checks within one year of the date this Form was signed by me, provided, however, that

_______________________________________________________________________________, must first provide me

(Organization)

with written notice of this check.

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.

_ __________________________________________________________

_________________________________

Signature of CORI Subject

Date

Criminal Offender Record Information (Cori) Acknowledgement Form - Massachusetts Department Of Criminal Justice Information Services

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