CORI Form by 027Jt0


									                        HENRY T. WING SCHOOL
                                               33 Water Street
  Sheila Lima                           Sandwich, Massachusetts, 02563

Joanna Hughes                                                                                   Dr. C. Richard Canfield
Assistant Principal                                                                             Superintendent of Schools

                                            CORI REQUEST FORM
                                                                                                              CH 385 G

   SANDWICH PUBLIC SCHOOLS has been certified by the Criminal History Systems Board for access to all criminal
   case data including convictions, non-conviction and pending. As an applicant/employee for the positions of
   ____________________________, I understand that a criminal record check will be conducted for conviction, non-
   conviction and pending criminal case information only and that it will not necessarily disqualify me. The information
   below is correct to the best of my knowledge.

                      __________________________________________                                ________________
                             Applicant/Employee Signature                                            Date

   Present Address: _______________________________________________________________

                             APPLICANT/EMPLOYEE INFORMATION (Please Print)

   _____________________________                      _____________________                     _____________________
                 Last Name                                     First Name                              Middle Name

   _____________________________________                                            _______________________________
      Maiden Name or Alias (if applicable)                                                    Place of Birth

   ___/____/____                    _______-_______-_______                         ___________________________
    Date of Birth                    Social Security Number                             Mother's Maiden Name

   FORMER Address(es)        _________________________________            _____________________________________

                             _________________________________            _____________________________________

   SEX:     M F            HEIGHT: _____ft. _____ in.           WEIGHT: ______                EYE COLOR _________

   MASSACHUSETTS DRIVER'S LICENSE NUMBER:                       ________________________________________

   ***The Above Information Was Verified By Reviewing The Following Form of Government Issued
      Photographic Identification:

                   DRIVER'S LICENSE (Attach Copy)
                   OTHER - Please specify _________________________________________ (Attach Copy)

   REQUESTED BY:       __________________________________________________________
                                    Signature of CORI Authorized Employee

                                     Sandwich Public Schools is an Equal Opportunity Employer

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