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NEWTON YOUTH LACROSSE CORI FORM

 

Newton Lacrosse is requesting all the available criminal offender record information (CORI) on the

following individual from the Criminal History Systems Board pursuant to GL c. 6s. 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 employees, volunteers, vendors or contractors.

*** VOLUNTEER INFORMATION (PLEASE TYPE) ***

___________________________        ________________________      ________________________

Last Name                                            First Name                              Middle Name

______________________________                     ______________________________________________

Maiden Name or Alias (If Applicable)                        Place of Birth (City, State, Country)

_________________________          _____- ________               _______________

Date of Birth (mm/dd/yyyy)               Social Security Number         ID Theft Index PIN

                                                                                            (Last 6 numbers- REQUIRED)                                  (If available)

______________________________

Mother’s Maiden Name

Height_____ ft _____ in ~ Weight ______ in lbs ~ Eye Color ________ SEX Male Female

(Check One)

Driver License Number _______________ State _________

Current Address .

________________________________    _________________________   ______   __________

Street and number                                       City                                        State           Zip

Former Address .

________________________________     _________________________     ______      __________

Street and number                                       City                                          State             Zip

 

 

THE INFORMATION WAS VERIFIED WITH THE FOLLOWING FORM OF GOVERNMENT ISSUED PHOTOGRAPHIC IDENTIFICATION.

Form of Picture ID: ____________________________________________________________

Requested by: ________________________________________________________________

 

Signature of CORI Authorized Employee

 

*If an applicant has provided an Identity Theft PIN number on this form, please ONLY mail or fax forms

with Identity Theft PIN numbers to DSJIS. All other CORI request must be processed electronically

through Web-CORI. Do not mail or fax other forms to DCJIS

Rev 2012