SSCYC, INC.

"A Vacation with a Purpose"

CRIMINAL OFFENDER RECORD INFORMATION (CORI)

ACKNOWLEDGEMENT FORM

SSCYC, Inc. is registered under the provisions of M.G.L. c. 6, &sect 172 to receive CORI for the purposes 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 license, 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 SSCYC, Inc. 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 SSCYC, Inc. written notice of my intent to withdraw consent to a CORI Check.

FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY: the SSCYC, Inc. may conduct subsequent CORI checks within one (1) year of the date this form was signed by me, provided, however, that SSCYC, Inc. must first provide me with written notice of this check.

PERSONAL INFORMATION

Full Name	First Name Middle Name Last Name Suffix
Gender
Current Address	Street Address
	City State Zip Code
	How long have you lived at this address? Year(s) Month(s)

Previous Address	Street Address
	City State Zip Code
	How long have you lived at this address? Year(s) Month(s)
Maiden Name	Maiden Name (last only) or other name(s) by which you have been known (if applicable)
Place of Birth	City State
Driver's License	License Number State Issued
Height	Feet Inches
Eye Color	Eye Color
Race	Race
Date of Birth	MM/DD/YYYY
Social Sec. # (Last 6)	***-XX-XXXX
Email Address	Email Address

PARENT INFORMATION

Mother's Name	First Name Last Name Maiden Last Name
Father's Full Name	First Name Last Name Suffix

SUBMISSION INSTRUCTIONS

Please type your name below and review your digital signature.

By clicking "Submit Form", you consent to a CORI check and declare that the information provided on this Acknowledgement Form is true and accurate.

Print your name Date
Signature

Upon clicking "Submit Form" you will be taken to a confirmation page and a copy of the acknowledgement form will be sent to the address provied above.

You must scan or take a photo of the front and rear of your drivers license and email to photos@sscyc.org to complete your form submission.