Cori Request Form

***CORI Request Form***

Bedford Babe Ruth Baseball/Softball will request all the available criminal offender record information (CORI) for volunteers from the Criminal History Systems

Board pursuant to Chapter 6 & 172H which mandates organizations primarily engaged in providing activities or programs to children 18 years of age or less that

accepts volunteers, to obtain all CORI regarding volunteers prior to accepting any person as a volunteer.

Last Name: _____________________________First Name:__________________ Middle Name:__________________

Maiden Name or Alias (if applicable): ___________________________________ Date of Birth: __________________

Mother's full name (inc Maiden)

Mother’s Maiden Name: _____________________________________________ Place of Birth:__________________

Father's full name

Address: ________________________________________________________________________________________

Former Address: __________________________________________________________________________________

Social Security Number (Optional): ___________________________________________________________________

Last six (6) digits of Social Security Number

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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:

________________________________________________________________________________________________

Signature of CORI authorized employee: _______________________________________

Date: _________________