Get Fall River Public Schools Cori Form

For Office Use Only Date FALL RIVER PULIC SCHOOLS Authorization Given 417 Rock Street Fall River MA 02720 Meg Mayo-Brown Superintendent CORI REQUEST FORM Fall River Public Schools has been certified by the Criminal History Systems Board for access to all criminal case data including conviction non-conviction and pending. As an applicant/employee for the position indicated below I understand that a criminal record check will be conducted for conviction non-conviction and pending criminal case information only and that it will not necessarily disqualify me. The information below is correct to the best of my knowledge. Position desired please select one o Employee o Renewal o Other o Volunteer at Name of School Date of Signature Applicant/Employee Signature APPLICANT/EMPLOYEE INFORMATION please print Last Name First Name Middle Name Maiden Name or Alias Place of Birth Mother s Maiden Name ID Theft Index if applicable Social Security Number REQUIRED Date of Birth Current Address Street Name Number City State Zip Code ForMer Address in* Sex Height Eye Color State Driver s License Number wrolwramor The above information was verified by reviewing the following form of government issued photographic identification Requested by Signature of CORI authorized employee The CHSB IdentifY Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft 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. As an applicant/employee for the position indicated below I understand that a criminal record check will be conducted for conviction non-conviction and pending criminal case information only and that it will not necessarily disqualify me. The information below is correct to the best of my knowledge. Position desired please select one o Employee o Renewal o Other o Volunteer at Name of School Date of Signature Applicant/Employee Signature APPLICANT/EMPLOYEE INFORMATION please print Last Name First Name Middle Name Maiden Name or Alias Place of Birth Mother s Maiden Name ID Theft Index if applicable Social Security Number REQUIRED Date of Birth Current Address Street Name Number City State Zip Code ForMer Address in* Sex Height Eye Color State Driver s License Number wrolwramor The above information was verified by reviewing the following form of government issued photographic identification Requested by Signature of CORI authorized employee The CHSB IdentifY Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft PIN Number by the CHSB. The information below is correct to the best of my knowledge. Position desired please select one o Employee o Renewal o Other o Volunteer at Name of School Date of Signature Applicant/Employee Signature APPLICANT/EMPLOYEE INFORMATION please print Last Name First Name Middle Name Maiden Name or Alias Place of Birth Mother s Maiden Name ID Theft Index if applicable Social Security Number REQUIRED Date of Birth Current Address Street Name Number City State Zip Code ForMer Address in* Sex Height Eye Color State Driver s License Number wrolwramor The above information was verified by reviewing the following form of government issued photographic identification Requested by Signature of CORI authorized employee The CHSB IdentifY Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft 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.