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info@yambacare.com

1(857) 777-9544

2 Burlington Woods Dr., Suite 100 Burlington, MA 01803.

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Name
First Last
Preferred Name (if different from First Name)
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
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Please upload or take a photo of your Identification.*
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CRIMINAL OFFENDER RECORD INFORMATION (CORI) ACKNOWLEDGEMENT FORM.*
TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT, VOLUNTEER,
SUBCONTRACTOR, LICENSING, AND HOUSING PURPOSES.

The Office of the Secretary of the Commonwealth Securities Division is registered under the provisions of MASS. GEN. LAWS c. 6, § 172 to receive CORI for the purpose of screening
current and otherwise qualified prospective employees, subcontractors, volunteers, license
applicants, current licensees, 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 Massachusetts DCJIS (" Department of Criminal Justice Information Services"). I hereby acknowledge and provide permission to the Office of the Secretary of the Commonwealth Securities Division to submit a CORI check for my
information to the DCJIS. This authorization is valid for one (1) year from the date of my
signature. I may withdraw this authorization at any time by providing the Office of the Secretary
of the Commonwealth Securities Division written notice of my intent to withdraw consent to a CORI check.

FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:

The Office of the Secretary of the Commonwealth, Securities Division may conduct subsequent CORI checks within one (1) year of the date this form was signed by me provided; however, that The Office of the Secretary of the Commonwealth, Securities Division 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. .
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Name*
First Middle Last
Maiden Name (or other name(s) by which you have been known)
Former Last Name 1 Former Last Name 2 Former Last Name 3 Former Last Name 4
Date of birth*
MM slash DD slash YYYY
Place of Birth*
Last Six Digits of Your Social Security Number:*
*
Sex: Height: Eye Color: Race:
Identification:*
Driver’s License or ID Number: State of issue:
Parent's Information:
Mother's Full Maiden Name: Father's Full Name
Current and Former Addresses:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

1(857) 777-9544

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info@yambacare.com

1(857) 777-9544

2 Burlington Woods Dr., Suite 100 Burlington, MA 01803.

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Former Last Name 1	Former Last Name 2	Former Last Name 3	Former Last Name 4

Sex:	Height:	Eye Color:	Race:

Driver’s License or ID Number:	State of issue:

Mother's Full Maiden Name:	Father's Full Name