Get Girl Scouts Cori Form

PTGSC FE 068 CORI REQUEST FORM Girl Scouts of Eastern Massachusetts Inc. is requesting all the available criminal offender record information CORI on the following individual from the Criminal History Systems Board pursuant to Chapter 6 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 volunteers prior to accepting any person as a volunteer. PLEASE PRINT TODAY S DATE POSITION APPLIED FOR TROOP LAST NAME MIDDLE NAME FIRST NAME MOTHER S MAIDEN NAME PHONE NUMBER MAIDEN NAME OR ALIAS IF APPLICABLE PLACE OF BIRTH DATE OF BIRTH ID Theft Index PIN if applicable SOCIAL SECURITY NUMBER requested but not required CURRENT ADDRESS FORMER ADDRESS SEX HEIGHT ft. in* STATE DRIVER S LICENSE NUMBER EYE COLOR STATE OF ISSUE IDENTIFICATION VERIFICATION Information below this line is to be completed by a GSEM CORI Authorized Representative only. THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE FOLLOWING FORM OF GOVERNMENT ISSUED PHOTOGRAPHIC IDENTIFICATION Form of Identification Reviewed Expiration Date REQUESTED BY SIGNATURE OF CORI AUTHORIZED REPRESENTATIVE THIS FORM MUST BE RETURNED IN PERSON TO A GSEM CORI AUTHORIZED REPRESENTATIVE* IT MUST NOT BE MAILED OR FAXED TO GSEM OR ANY OTHER ORGANIZATION* DATE REVIEWED 09-01-10 The CHSB Identify Theft PIN Number is to be completed by those applicants that have been issued an Identify 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. All CORI request forms that include this field are required to be submitted to the CHSB via mail or fax. PLEASE PRINT TODAY S DATE POSITION APPLIED FOR TROOP LAST NAME MIDDLE NAME FIRST NAME MOTHER S MAIDEN NAME PHONE NUMBER MAIDEN NAME OR ALIAS IF APPLICABLE PLACE OF BIRTH DATE OF BIRTH ID Theft Index PIN if applicable SOCIAL SECURITY NUMBER requested but not required CURRENT ADDRESS FORMER ADDRESS SEX HEIGHT ft. in* STATE DRIVER S LICENSE NUMBER EYE COLOR STATE OF ISSUE IDENTIFICATION VERIFICATION Information below this line is to be completed by a GSEM CORI Authorized Representative only. in* STATE DRIVER S LICENSE NUMBER EYE COLOR STATE OF ISSUE IDENTIFICATION VERIFICATION Information below this line is to be completed by a GSEM CORI Authorized Representative only. THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE FOLLOWING FORM OF GOVERNMENT ISSUED PHOTOGRAPHIC IDENTIFICATION Form of Identification Reviewed Expiration Date REQUESTED BY SIGNATURE OF CORI AUTHORIZED REPRESENTATIVE THIS FORM MUST BE RETURNED IN PERSON TO A GSEM CORI AUTHORIZED REPRESENTATIVE* IT MUST NOT BE MAILED OR FAXED TO GSEM OR ANY OTHER ORGANIZATION* DATE REVIEWED 09-01-10 The CHSB Identify Theft PIN Number is to be completed by those applicants that have been issued an Identify Theft Index PIN Number by the CHSB. THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE FOLLOWING FORM OF GOVERNMENT ISSUED PHOTOGRAPHIC IDENTIFICATION Form of Identification Reviewed Expiration Date REQUESTED BY SIGNATURE OF CORI AUTHORIZED REPRESENTATIVE THIS FORM MUST BE RETURNED IN PERSON TO A GSEM CORI AUTHORIZED REPRESENTATIVE* IT MUST NOT BE MAILED OR FAXED TO GSEM OR ANY OTHER ORGANIZATION* DATE REVIEWED 09-01-10 The CHSB Identify Theft PIN Number is to be completed by those applicants that have been issued an Identify 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.