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Criminal Offender Record Information (Cori) Acknowledgement Form - Massachusetts Department Of Criminal Justice Information Services Page 2

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

SUBJECT INFORMATION

Please complete this section using the information of the person whose CORI you are requesting.

The fields marked with an asterisk (*) are required fields.

* First Name: ________________________________________________________ Middle Initial: _________________

* Last Name:_________________________________________________________ Suffix (Jr., Sr., etc.): _____________

Former Last Name 1: _______________________________________________________________________________

Former Last Name 2: _______________________________________________________________________________

Former Last Name 3: _______________________________________________________________________________

Former Last Name 4: _______________________________________________________________________________

* Date of Birth (MM/DD/YYYY): ___________________ Place of Birth: ________________________________________

* Last SIX digits of Social Security Number: ___ ___ ‐‐ ___ ___ ___ ___ ☐ No Social Security Number

Sex: _________________ Height: _____ ft. _____ in. Eye Color: _______________ Race: ______________________

Driver’s License or ID Number: ______________________________________ State of Issue: ____________________

Father’s Full Name: ________________________________________________________________________________

Mother’s Full Name: _______________________________________________________________________________

Current Address

* Street Address: ____________________________________________________________________________________

Apt. # or Suite: _____________ *City: __________________________ *State: ________ *Zip: _______________

SUBJECT VERIFICATION

The above information was verified by reviewing the following form(s) of government‐issued identification:

__________________________________________________________________________________________________

Verified by:

_ __________________________________________________________

Print Name of Verifying Employee

_ __________________________________________________________

_________________________________

Signature of Verifying Employee

Date

Criminal Offender Record Information (Cori) Acknowledgement Form - Massachusetts Department Of Criminal Justice Information Services Page 2