Criminal Offender Record Information (Cori) Acknowledgement Form Page 2
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2SUBJECT INFORMATION: (An asterisk (*) denotes a required field)
________________________ _________________________ _______________________ ______
*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: ______ - _____________
Sex: ______
Height: ____ ft. ____ in.
Eye Color: ___________
Driver’s License or ID Number: ___________________
State of Issue: ________________________
Current and Former Addresses:
______ ____________________________________ ______________________ _____ ________
Number
Name
City/Town
State
Zip
______ ____________________________________ ______________________ _____ ________
Number
Name
City/Town
State
Zip
SECTION A: VERIFICATION BY DPL EMPLOYEE: I hereby certify that I verified the identity of the
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above-referenced subject by reviewing the following form(s) of government-issued identification:
State-issued driver’s license
Passport
Military identification
State-issued identification card
VERIFIED BY:
Name of Verifying DPL Employee (Please Print)
Signature of Verifying DPL Employee (Please Print)
Date
SECTION B: VERIFICATION BY NOTARY:
On this ______ day of _____________, 20____, before me, the undersigned notary public, personally
appeared _________________________________ (name of document signer), and proved to me
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through satisfactory evidence of identification, which was the following:
State-issued driver’s license
Military identification
Passport
State-issued identification card
to be the person whose name is signed on the preceding or attached document, and acknowledged to
me that (he) (she) signed it voluntarily for its stated purpose.
Notary Public:
Notary Commission Expires On:
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If a subject does not have an acceptable government-issued identification, his or her identity shall be verified by the other
forms of identification documentation as determined by DCJIS. 803 CMR 2.09 (2).
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