CRIMINAL OFFENDER RECORD INFORMATION (CORI) ACKNOWLEDGEMENT FORM

TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT.

VOLUNTEER. SUBCONTRACTOR. LICENSING. AND HOUSING PURPOSES.

American Personnel Inc. dba AP Staffing is registered under the provisions of M.G.L. 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 DCJIS. I hereby acknowledge and provide permission to American Personnel Inc. dba AP Staffing 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 American Personnel Inc. dba AP Staffing written notice of my intent to withdraw consent to a CORI check.

FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:

The Employer (American Personnel Inc. dba AP Staffing) may conduct subsequent CORI checks within one year of the date this Form was signed by me provided, however, that American Personnel Inc. 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.

Nilsa mendez

SIGNATURE DATE

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SUBJECT INFORMATION: (A red asterisk denotes a required field)

Mendez

*Last Name

*First Name Middle Name Suffix

Maiden Name (or other name(s) by which you have been known)

*Date of Birth Place of Birth

*Last Six Digits of Your Social Security Number:

Sex: Height: _ft._ in. Eye Color: Race: Driver's License or 10 Number: State of Issue:

Mother's Full Maiden Name

Father's Full Name

Current and Former Addresses:

Street Number & Name

City/Town

State

Zip

Street Number & Name

City/Town

State

Zip

The above information was verified by reviewing the following form(s) of government-issued identification:

VERIFIED BY:

Name of Verifying Employee (Please Print)

Signature of Verifying Employee

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