CORI Form by 027Jt0

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

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



                                            CORI REQUEST FORM
                                                                                                               SANPS
                                                                                                              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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