Fillable Cape Cod And Islands Council, Inc. - Boy Scouts Of America printable pdf download

Cape Cod and Islands Council, Inc. #224

Boy Scouts of America

Serving Cape Cod, Martha’s Vineyard, and Nantucket Islands

Agency Code: CGCCI

172H

FE172

Chapter 6, Sec. 172H CORI REQUEST FORM

Cape Cod & Islands Council, Inc., Boy Scouts of America, is requesting all the available criminal offender record information (CORI)

on the following individual from the Criminal History Systems Board pursuant to Chapter 6, Sec. 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 staff and volunteers. A copy of the Cape Cod & Islands Council CORI policy is available on our website or may be obtained

by contacting the Council Service Center at 508-362-4322.

Applicant Information (Please Print)

______________________________

__________________________ ___________________

Last Name

First Name

Middle Name

________________________________________________

_______________________________

Maiden Name or Alias (If applicable)

Place of Birth

_________________________ _______-________-_________ ________________

__________________________

Date of Birth

Social Security Number

ID Theft Index PIN*

Mother’s Maiden Name

(Required)

Current and Former Addresses _________________________________________________________________

________________________________________________________________________________

Sex: ______ Height: ____ ft. ____ in.

Weight: ________ Eye Color: ___________

State Driver’s License Number: ____________________________________________________

This information was verified by reviewing the following form of government issued photographic identification: (Driver’s

License, Passport, etc.) ____________________________________________

____________________________________________________________

Signature of Unit Committee Chairman

I understand that any person who willfully requests, obtains or seeks to obtain criminal offender record information (CORI) under false pretenses, or

who willfully communicates or seeks to communicate CORI to any agency or person except in accordance with the provisions of M.G.L. c. 6, §§168

through 178B, inclusive, shall for each offense be fined not to exceed five thousand dollars ($5,000.00), or imprisoned in a jail or house of correction

for up to one year, or both and/or may be ordered by the Criminal History Systems Board to pay civil fines not to exceed five hundred ($500.00) for

each willful violation.

*The CHSB Identify Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft Index PIN Number by the

CHSB. Certified agencies are required to provide all applicants the opportunity to include this information to ensure the accuracy of the CORI request

process.

Please attach a copy of the applicant’s photo ID to this form.

Rev 10/25/2010

Tel. (508) 362-4322

247 Willow Street

Fax (508) 362-4323

Yarmouth Port, MA 02675