Ymca Of Greater Springfield Volunteer Services Application Page 3
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3YMCAS
172zG
FE052
CHAPTER 6, §172G CORI REQUEST FORM
YMCA of Greater Springfield is requesting all available criminal offender record
information (CORI) and juvenile data on the following individual from the Criminal
History Systems Board pursuant to Chapter 6, §172G, which mandates operators of
camps for children to request CORI and juvenile data regarding all employees or
prior to employment or volunteer service.
_______________________________________________________________________
APPLICANT/EMPLOYEE INFORMATION (PLEASE PRINT)
_________________________
________________________
_______________
LAST NAME
FIRST NAME
MIDDLE NAME
______________________________________
_______________________
MAIDEN NAME OR ALIAS (IF APPLICABLE)
PLACE OF BIRTH
_________________ _______-________-_______
_______________________
DATE OF BIRTH
SOCIAL SECURITY NUMBER
MOTHER’S MAIDEN NAME
(last 6 digits only)
CURRENT AND FORMER ADDRESSES:____________________________________
________________________________________________________________________
SEX: ____
HEIGHT:____ft. ___in.
WEIGHT:______ EYE COLOR:_________
__________
_
STATE DRIVER’S LICENSE NUMBER:________________________________
***THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE
FOLLOWING FORM OF GOVERNMENT ISSUED PHOTOGRAPHIC
IDENTIFICATION:_____________________________________________________________.
REQUESTED BY:_______________________________________________________________
SIGNATURE OF CORI AUTHORIZED EMPLOYEE
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