of 1
Current View
District: ____
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______
Program: _____
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Season: __
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MASMA12
-
03053
Massachusetts Hockey, Inc.
is requesting all the available criminal offender record information (CORI) on the
following individual from the Criminal History Syst
ems 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 Addres
s .
________________________________ _______________
__________ ______ __________
Street and number City State Zip
T
HE INFORMATION WAS V
ERIFIED WITH THE FOL
LOWING FORM OF GOVER
NMENT ISSUED
P
HOTOGRAPHIC IDENTIFI
CATION
.
Form of
Picture ID: ____________________________________________________________
Requested by: ________________________________________________________________
Signature of CORI Authorized Employee
*
If an applicant h
as 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