CORI Request Form

INVESTIGATIONS
LOSS PREVENTION
INTEGRITY AUDITS
MYSTERY SHOPPING AUDITS
BACKGROUND CHECKS
UNDERCOVER OPERATIVES
CORPORATE HEADQUARTERS
776R WASHINGTON STREET
CANTON, MA 02021
(617) 437-0030 • (800) 292-9797
FAX (617) 437-0034
WWW.DATAQUEST.CO
CRIMINAL OFFENDER RECORD INFORMATION (CORI)
ACKNOWLEDGEMENT FORM
TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT,
VOLUNTEER, SUBCONTRACTOR, LICENSING, AND HOUSING PURPOSES.
Data Quest, Ltd. 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, license applicants, current licenses, and applicants for the rental or lease of housing.
As a prospective or current employee, subcontractor, volunteer, license applicant, current
licensee, or applicant for the rental or lease of housing, I understand that a CORI check will be
submitted for my personal information to the DCJIS. I hereby acknowledge and provide
permission to Data Quest, Ltd. 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 Data Quest, Ltd. with written notice of my intent to
withdraw consent to a CORI check.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:
Data Quest, Ltd. may conduct subsequent CORI checks within one year of the date of this Form
was signed by provided, however, that Data Quest, Ltd. 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 Page 2 of this Acknowledgement Form is true and accurate.
SIGNATURE
DATE
SUBJECT INFORMATION:
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 (Required):
Sex:
Height:
ft.
in.
Eye Color:
Driver’s License or ID Number:
Race:
State of Issue:
Mother’s Full Maiden Name
Father’s Full Name
Current and Former Addresses:
Street Number & Name
City/Town
State
Zip
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 Employee (Please Print)
Signature of Verifying Employee