Acknowledgement Form For Sandwich Little League
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1CRIMINAL OFFENDER RECORD INFORMATION (CORI)
ACKNOWLEDGEMENT FORM for SANDWICH LITTLE LEAGUE
TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT, VOLUNTEER, SUBCONTRACTOR, OR LICENSING PURPOSES
Sandwich Little League 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, volunteers, and license applicants.
As a prospective or current employee, subcontractor, volunteer, or license applicant, I understand that a CORI check will be
submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to Sandwich Little League 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 Sandwich Little League with written notice of my intent to withdraw consent to
a CORI check.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY: Sandwich Little League may conduct subsequent CORI checks
within one year of the date this Form was signed by me provided, however, that Sandwich Little League 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 this Acknowledgement
Form is true and correct.
______________________________________________________ ______________________________________
SIGNATURE
DATE
__________________________________________________________________________________________________
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: XXX‐____________‐_________________
Sex: ________
Height: ______ft.______ in.
Eye Color: __________ Race: _____________
Driver’s License or ID Number: _________________________________ State:_________
Current and Former Addresses:
_____________________________________________________________________________________________
Street Number & Name
City/Town
State Zip
_____________________________________________________________________________________________
Street Number & Name
City/Town
State Zip
The above information was verified by reviewing the following form(s) of government‐issued identification:
________________________________________
VERIFIED BY: ______________________________________________ ________________________________
Name of Verifying Agent (Please Print)
Signature of Verifying Agent
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