City of Worcester, Massachusetts Michael V. O’Brien Timothy J. McGourthy City Manager Chief Development Officer Executive Office of Economic Development Joel J. Fontane Director Planning & Regulatory Services Division LIQUOR LICENSE APPLICATION CHECKLIST Instructions: 1. Fill out the attached application completely (please type or print; illegible applications will be returned). 2. Check Zone for availability with Division of Planning & Regulatory Services, (508) 799-1400 ext 260. 3. Obtain a List of Abutters (obtained at the Assessor’s Office). It is the applicant’s responsibility to notify abutters within three (3) days after the advertisement appears by certified mail return receipt. 4. Obtain a Right of Entry/Purchase Sale Agreement, Copy of Lease or Notice from landlord. It is required that there must be a statement from the landlord giving permission for liquor to be on the premises. 5. Provide proof of Sole Proprietorship (if one owner of entire business). 6. Provide proof of Partnership (if a contract entered into by two or more persons where each agrees to furnish part of the capital and labor for a business enterprise, and by which each shares in some fixed proportion in profit and losses). 7. Provide proof of Corporation or LLC (if a body of persons granted a charter legally recognizing it as a separate entity having its own rights and privileges and liabilities distinct from those of its members). 8. Provide a plan of the premises. If there will be alcohol stored in basement or alcohol served outside, that must be shown on plan. 9. Provide a Business Plan (how the business will be managed). 10. Provide a recent Certificate of Good Standing (for an established corporation). This can be obtained from Department of Revenue, 1-800-392-6089. License Commission, Planning & Regulatory Services Division 455 Main Street Room 404, Worcester, MA 01608 Phone: (508) 799-1400 ext. 234, Fax: (508) 799-1406 email@example.com 11. Provide documentation of all sources of financing (loan papers, checking accounts, stock sales, etc.). Applicant must provide copies of where the financing comes from. 12. Complete the Personal Information Sheet and CORI for any person who will have an ownership in the business. 13. Provide a copy of the manager’s birth certificate, passport or Certificate of Naturalization. 14. Complete Form C (attached) financing form. 15. Obtain a Business Certificate (may be obtained in the City Clerk’s Office, Room 206, City Hall). 16. If a restaurant, submit a copy of the proposed menu. 17. If this is a license transfer application, a copy of the Purchase and Sale Agreement must be provided. 18. Submit original completed application plus six (6) copies; no staples. 19. Filing fees: after application is processed, you will be billed $50.00 for the Liquor Application Filing and $50.00 for the Liquor Advertising Fee. If filing on the deadline date, the application must be filed by 2:00 PM. 20. At the time of your hearing, you will need to bring a check for $200.00 payable to the A.B.C.C. and proof of Notice to Abutters (certified green return receipt cards). Applications will NOT be accepted without all required paperwork. License Commission, Planning & Regulatory Services Division 455 Main Street Room 404, Worcester, MA 01608 Phone: (508) 799-1400 ext. 234, Fax: (508) 799-1406 firstname.lastname@example.org Commonwealth of Massachusetts Department of the State Treasurer Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 Telephone: (617) 727-3040 Fax: (617) 727-1258 Timothy P. Cahill Kim S. Gainsboro Treasurer and Receiver General Chairman ALCOHOLIC BEVERAGES CONTROL COMMISSION ADVISORY MANDATORY LIQUOR LIABILITY INSURANCE On May 28, 2010 the legislature amended M.G.L. c. 138, §12 by requiring existing licensees and applicants for alcoholic beverages licenses issued under M.G.L. c. 138, §12, to have a MINIMUM AMOUNT OF MANDATORY LIQUOR LIABILITY INSURANCE COVERAGE. Effective August 26, 2010, no license under M.G.L. c. 138, §12 shall be issued or renewed until the applicant or licensee provides proof of mandatory insurance coverage by filing a certificate of insurance in a form acceptable to the local licensing authority (“LLA”). As a result, applicants for §12 licenses must provide proof of insurance coverage under a liquor legal liability insurance policy for bodily injury or death for a minimum amount of $250,000 on account of injury to or death of 1 person, and $500,000 on account of any 1 accident resulting in injury to or death of more than 1 person as a condition to receive a license. Existing §12 licensees, which include any entities wishing to transfer a license, must provide proof of insurance coverage under a liquor legal liability insurance policy for bodily injury or death for a minimum amount of $250,000 on account of injury to or death of 1 person, and $500,000 on account of any 1 accident resulting in injury to or death of more than 1 person as a condition to renew a license. Although LLA’s retain the discretion to set the amount of insurance coverage required pursuant to M.G.L. c. 138, §64A for §12 licensees that are repeat offenders in selling or serving alcoholic beverages to under-age or intoxicated individuals, they DO NOT have the discretion to increase the minimum amount of insurance coverage required by this new law. Moreover, LLA’s should be aware that licensees have the ability to appeal an action of the LLA in requiring insurance pursuant to M.G.L. c. 138, §64A and that after hearing, the ABCC, retains the discretion to modify this amount pursuant to M.G.L. c. 138, § 67. As a result of this amendment, the ABCC will be revising the renewal applications for calendar year 2011 to ensure compliance with this new LIQUOR LIABILITY INSURANCE law. Individuals with questions concerning this Advisory may contact the ABCC at 617-727-3040 x 31. (Issued July 27, 2010) NOTICE EFFECTIVE NOVEMBER 15, 2004, AS REQUIRED BY CHAPTER 304 OF THE ACTS OF 2004, AN ACT RELATIVE TO FIRE SAFETY IN THE COMMONWEALTH, EVERY LICENSE HOLDER UNDER M.G.L. C. 138 SEC 12 MUST SUBMIT AS A CONDITION OF A LICENSE A VALID CERTIFICATE OF INSPECTION ISSUED BY A LOCAL INSPECTOR AND SIGNED BY THE HEAD OF THE FIRE DEPARTMENT FOR THE CITY, TOWN, OR DISTRICT IN WHICH THE PREMISES IS LOCATED. Application for Retail Alcoholic Beverage License City/Town Worcester, MA 1. Transaction: New License New Officer/Director Transfer of Stock Issuance of Stock Transfer of License New Stockholder Management/Operating Agreement The following transactions must be processed as new licenses: Seasonal to Annual 6-Day to 7-Day License Wine & Malt to All Alcohol IMPORTANT ATTACHMENTS: The applicant must attach a vote of the entity authorizing all requested transactions, including the appointment of a Manager of Record or principal representative. 2. Type of License: §12 Restaurant §12 Hotel §12 Club §12 Veterans Club §12 General On-Premise §12 Tavern (No Sundays) §15 Package Store 3. License Catagory: All Alcoholic Beverages Wine & Malt Beverages Only Wine or Malt Only Wine & Malt Beverages with Cordials/Liqueurs Permit 4. License Class: Annual Seasonal 5. Contact Person concerning this application (attorney if applicable) NAME: ADDRESS: CITY/TOWN: STATE ZIP CODE CONTACT PHONE NUMBER: FAX NUMBER: EMAIL: 6. Licensee Information: Legal Name/Entity of Applicant:(e.g Corporation, LLC, Individual) Business Name (if different) : Manager of Record: ABCC License Number (for existing licenses only) : Address of Licensed Premises: CITY/TOWN: STATE ZIP Business Phone: Cell Phone: Email: Website: 7. Description of Premises: Please provide a complete description of the premises to be licensed. The description should include the location of all entrances and exits. IMPORTANT ATTACHMENTS: The applicant must attach a floor plan with dimensions and square footage for each floor & room. Occupancy Number: Seating Capacity: 8. Occupancy of Premises: By what right does the applicant have possession and/or legal occupancy of the premises? Please Select IMPORTANT ATTACHMENTS: The applicant must submit a copy of the final lease or documents evidencing a legal right to occupy the premises. Other: Landlord is a(n): Please Select Other Name Phone: Address: City/Town: State Zip Initial Lease Term: Beginning Date Ending Date Renewal Term: Options/Extensions at Years Each Rent: per year Rent: per month Do the terms of the lease or other arrangement require payments to the Landlord based on a percentage of the alcohol sales? Yes No IMPORTANT ATTACHMENTS: If yes, the Landlord is deemed a person or entity with a financial or beneficial interest in this license. Each individual with an ownership interest in the Landlord must be disclosed in §10 and must submit a completed Personal Information Form attached to this application. Entity formation documents for the Landlord entity must accompany the application to confirm the individuals disclosed. 9. Licensee Structure: The Applicant is a(n): Please Select Other : If the applicant is a Corporation or LLC, complete the following: State of Incorporation/Organization: Date of Incorporation/Organization: Is the Corporation publicly traded? Yes No 10. Interests in this License: List all individuals involved in the entity (e.g. corporate stockholders, directors, officers and LLC members and managers) and any person or entity with a direct or indirect, beneficial or financial interest in this license (e.g. landlord with a percentage rent based on alcohol sales). IMPORTANT ATTACHMENTS: All individuals or entities listed below are required to complete a Personal Information Form. Name Title Stock or % Owned Other Beneficial Interest *If additional space is needed, please use last page. 11. Existing Interests in Other Licenses: Does any individual listed in §10 have any direct or indirect, beneficial or financial interest in any other license to sell alcoholic beverages? Yes No If yes, list said interest below: Name License Type Licensee Name & Address Please Select Please Select Please Select Please Select Please Select Please Select Please Select *If additional space is needed, please use last page. 12. Previously Held Interests in Other Licenses: Has any individual listed in §10 who has a direct or indirect beneficial interest in this license ever held a direct or indirect, beneficial or financial interest in a license to sell alcoholic beverages, which is not presently held? Yes No If yes, list said interest below: Reason Name Licensee Name & Address Date Terminated Please Select Please Select Please Select 13. Disclosure of License Disciplinary Action: Have any of the disclosed licenses to sell alcoholic beverages listed in §11 and/or §12 ever been suspended, revoked or cancelled? Yes No If yes, list said interest below: Date License Reason of Suspension, Revocation or Cancellation 14. Criminal Record: Has any individual listed in §10 or who has a direct or indirect beneficial interest in this license ever been convicted of a municipal, state, federal or military crime? Yes No If yes, the individual must provide an affidavit as to any and all charges as well as the disposition. 15. Citizenship and Residency Requirements for a (§15) Package Store License ONLY: 1. Are all Directors/LLC Managers U.S. Citizens? Yes No 2. Are a majority of Directors/LLC Managers Massachusetts Residents? Yes No 3. Is the License Manager or Principal Representative a U.S. Citizen? Yes No 4. Are all members and partners involved at least twenty-one years old? Yes No 16. Citizenship and Residency Requirements for (§12) Restaurant, Hotel, Club, General On Premise, Tavern, Veterans Club License ONLY: 1. Are all Directors/LLC Managers U.S. Citizens? Yes No 2. Are a majority of Directors/LLC Managers Massachusetts Residents? Yes No 3. Is the License Manager or Principal Representative a U.S. Citizen? Yes No 17. Costs Associated with License Transaction: A. Purchase Price for Real Property: B. Purchase Price for Business Assets: C. Costs of Renovations/Construction: D. Initial Start-Up Costs: IMPORTANT ATTACHMENTS: Submit any and all records, documents and affidavits including loan E. Purchase Price for Inventory: agreements that explain the source(s) of money for this transaction. Sources of cash should include a minimum F. Other: (Specify) of three (3) months of bank statements. G: TOTAL COST H. TOTAL CASH I. TOTAL AMOUNT FINANCED The amounts listed in subsections (H) and (I) must total the amount reflected in (G). 18. Provide a detailed explanation of the form(s) and source(s) of funding for the costs identified in §17 (include loans, mortgages, lines of credit, notes, personal funds, gifts): *If additional space is needed, please use last page. 19. List each lender and loan amount(s) from which "total amount financed" noted in subsections 17(I) will derive: Name Dollar Amount Type of Financing *If additional space is needed, please use last page. Does any individual or entity listed in §19 as a source of financing have a direct or indirect, beneficial or financial interest in this license or any other license(s) granted under Chapter 138? Yes No If yes, please describe: 20. Pledge: (i.e. collateral for a loan) Is the applicant seeking approval to pledge the license? Yes No If yes, describe terms and conditions and to whom: If a corporation, is the applicant seeking approval to pledge any of the corporate stock? Yes No If yes, to whom: Number of Shares Is the applicant pledging the inventory? Yes No If yes, to whom: IMPORTANT ATTACHMENTS: If you are applying for a pledge, submit the pledge agreement, the promissory note and a vote of the Corporation/LLC approving the pledge. 21. Construction of Premise Are the premises being remodeled, redecorated or constructed in any way? If YES, please provide a description of the work being performed on the premises: Yes No If all the information is not completed the application may be returned APPLICANT'S STATEMENT I, the: sole proprietor; partner; corporate principal; LLC/LLP member of , hereby submit this application for (hereinafter the “Application”), to the local licensing authority (the “LLA”) and the Alcoholic Beverages Control Commission (the “ABCC” and together with the LLA collectively the “Licensing Authorities”) for approval. I do hereby declare under the pains and penalties of perjury that I have personal knowledge of the information submitted in the Application, and as such affirm that all statement and representations therein are true to the best of my knowledge and belief. I further submit the following to be true and accurate: (1) I understand that each representation in this Application is material to the Licensing Authorities' decision on the Application and that the Licensing Authorities will rely on each and every answer in the Application and accompanying documents in reaching its decision; (2) I state that the location and description of the proposed licensed premises does not violate any requirement of the ABCC or other state law or local ordinances; (3) I understand that while the Application is pending, I must notify the Licensing Authorities of any change in the information submitted therein. I understand that failure to give such notice to the Licensing Authorities may result in disapproval of the Application; (4) I understand that upon approval of the Application, I must notify the Licensing Authorities of any change in the Application information as approved by the Licensing Authorities. I understand that failure to give such notice to the Licensing Authorities may result in sanctions including revocation of any license for which this Application is submitted; (5) I understand that the licensee will be bound by the statements and representations made in the Application, including, but not limited to the identity of persons with an ownership or financial interest in the license; (6) I understand that all statements and representations made become conditions of the license; (7) I understand that any physical alterations to or changes to the size of, the area used for the sale, delivery, storage, or consumption of alcoholic beverages, must be reported to the Licensing Authorities and may require the prior approval of the Licensing Authorities; (8) I understand that the licensee's failure to operate the licensed premises in accordance with the statements and representations made in the Application may result in sanctions, including the revocation of any license for which the Application was submitted; and (9) I understand that any false statement or misrepresentation will constitute cause for disapproval of the Application or sanctions including revocation of any license for which this Application is submitted. Signature: Date Title The Commonwealth of Massachusetts Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 www.mass.gov/abcc Personal Information Form Each individual listed in §10 of this application must complete this form. 1. Licensee Information: Legal Name of Licensee: Business Name (d/b/a) Address: ABCC License Number: (If existing licensee) City/Town State Zip Code Phone Number of Premise EIN of License: 2. Personal Information: Individual Name Home Phone Number: Address: City/Town State Zip Code Social Security Number Date of Birth Place of Employment Have you ever been convicted of a state, federal or military crime? Yes No If yes, attach an affidavit as to all charges and disposition. 3. Financial Interest: Provide a detailed description of your direct or indirect, beneficial or financial interest in this license. IMPORTANT ATTACHMENTS: For all cash contributions, attach last 3 months of bank statements for the source(s) of this cash. *If additional space is needed, please use the last page* I hereby swear under the pains and penalties of perjury that the information I have provided in this application is true and accurate: Signature Date Title (If Corporation/LLC Representative) The Commonwealth of Massachusetts Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 www.mass.gov/abcc Manager Application All proposed managers are required to complete a Personal Information Form, and attach a copy of the corporate vote authorizing this action and appointing a manager. 1. Licensee Information: Legal Name of Licensee: Business Name (d/b/a) Address: City/Town State Zip Code ABCC License Number: Phone Number of Premise (If existing licensee) 2. Manager Information: Name: Cell Phone Number: Are you a U.S. Citizen: Yes No Court and Date of Naturalization: (Submit proof of citizenship and/or naturalization such as Voter's Certificate, Birth Certificate or Naturalization Papers) List the number of hours per week you will spend on the licensed premises: Have you ever been charged or convicted of a state, federal or military crime? Yes No If yes, attach an affidavit as to all charges and disposition. Do you now, or have you ever, held any direct or indirect, beneficial or financial interest in a license to sell alcoholic beverages? Yes No If yes, please describe: Have you ever been the Manager of Record of a license to sell alcoholic beverages that has been suspended, revoked or cancelled? Yes No If yes, please describe: *If additional space is needed, please use the last page* Please list your employment for the past ten years (Dates, Position, Employer, Address and Telephone): *If additional space is needed, please use the last page* I hereby swear under the pains and penalties of perjury that the information I have provided in this application is true and accurate: Signature Date Additional Space Please note which question you are using this space for. THIS FORM TO BE FILLED OUT BY ANYONE WHO WILL HAVE DIRECT/INDIRECT INTEREST IN THE BUSINESS NAME SOCIAL SECURITY # DRIVER’S LICENSE # DATE OF BIRTH ARE YOU A UNITED STATES CITIZEN? WHERE WERE YOU BORN (CITY, STATE, COUNTRY) IDENTIFY YOUR CRIMINAL RECORD, (MASSACHUSETTS, MILITARY, ANY OTHER STATE OR FEDERAL COURT): ANY OTHER ARREST OR APPEARANCE IN CRIMINAL COURT CHARGED WITH A CRIMINAL OFFENSE REGARDLESS OF FINAL DISPOSITION: YES NO MUST CHECK EITHER YES OR NO IF YES, PLEASE DESCRIBE OFFENSE(S) SPECIFIC CHARGE AND DISPOSITION (FINE, PENALTY, ETC.) HOME ADDRESS TIME AT THIS ADDRESS PREVIOUS ADDRESS TIME AT THIS ADDRESS FATHER’S NAME MOTHER’S MAIDEN NAME HOME PHONE E-MAIL ADDRESS BUSINESS PHONE SCHOOLING HAVE YOU EVER BEEN IN THE MILITARY HONORABLE DISCHARGE YES NO NAME OF BUSINESS ADDRESS OF BUSINESS HOURS OF BUSINESS IDENTIFY FORMS OF FINANCING (THIS MUST BE PROVIDED OR APPLICATION WILL BE REFUSED BY WORCESTER POLICE DEPARTMENT) MORTGAGE: $ SELLER: $ CASH: $ OTHER (SPECIFY): $ Document all sources (e.g. – loan papers, checking accounts, stock sales, etc.) IF CORPORATION PLEASE FILL OUT FOLLOWING INFORMATION LIST OFFICERS & DIRECTORS PRESIDENT NAME: NAME: ADDRESS: ADDRESS: VICE PRESIDENT NAME: NAME: ADDRESS: ADDRESS: TREASURER: NAME: ADDRESS: ADDRESS: APPROVAL SHEET POLICE DEPARTMENT________________________________________ PUBLIC HEALTH______________________________________________ INSPECTIONAL SERVICES______________________________________ CHAPTER 304 CERTIFICATE___________________________________ CERTIFICATION OF COMPLIANCE WITH WORCESTER REVISED ORDINANCES GOVERNING REVENUE COLLECTION Pursuant to M.G.L. c. 40, section 57 and Worcester Revised Ordinances, Chapter 11, Article 2, Section 1, et. Seq., I hereby certify, under the pains and penalties of perjury, that the undersigned applicant, and all parties having an ownership interest therein have complied with the laws of the Commonwealth of Massachusetts and the City of Worcester regarding payment of all local taxes, fees, assesments, betterment’s or any other municipal charges of any kind. GIVE FULL NAMES AND RESIDENCES OF ALL PERSONS AND PARTIES INTERESTED IN THIS APPLICATION (Give first and last name if full: in case of a corporation give names of President, Treasurer and Manager, and in case of firms, give names of individuals members) 1 IF A PROPRIETORSHIP Name of Owner Business Address Home Address Business Phone Home Phone 2 IF A PARTNERSHIP Full names and addresses of all partners NAMES ADDRESS Business Address Business Phone 3 IF A CORPORATION Full legal name State of incorporation Principal place of business Principal place of business in Massachusetts Officers in Corporation NAME TITLE 4 If a Trust Name of Trust Business Address NAMES OF TRUSTEES ADDRESS (Use additional sheets if necessary) DATED THIS DAY OF By Name Title Business Address Social Security or Federal I.D. No. CERTIFICATE OF COMPLIANCE PROVIDING COMPLIANCE WITH THE WORKERS’ COMPENSATION ACT Section 25C of Chapter 152 Massachusetts Laws requires that every local licensing authority shall withhold the issuance or renewal of a license or permit to operate a business or to construct a building(s) in the Commonwealth until it has received acceptable evidence of compliance with the Worker’s Compensation Insurance coverage required by law. As a person or company seeking a license or permit to operate a business or to construct buildings or the renewal of such a license or permit, you must supply one of the following by attaching it to the CERTIFICATE OF COMPLIANCE. (Please check one): ( ) A certificate of insurance showing workers’ compensation insurance in effect as of the date upon which issuance or renewal of a license or permit is requested ( ) A copy of a policy of workers’ compensation insurance in effect as of the date upon which the issuance or renewal of the license or permit is requested In certain circumstances, listed below, workers’ compensation insurance is not required. If one of the situations applies to you, please check off the appropriate exemption and sign the statement where indicated before a Notary Public, who will then notarize the sworn statement: COMMONWEALTH OF MASSACHUSETTS) COUNTY OF WORCESTER ) SS. ( ) I am self employed and have no employees who work for me, and do all the work of my business, named at , Worcester, myself. Therefore, I am not required to obtain workers’ compensation insurance. ( ) I and are the owners of the business named at , Worcester and we have no employees. Therefore, we are not required to obtain workers’ compensation insurance. I certify that the above is true and correct under the pains and penalties of perjury this day of 20 Signature Sworn to and subscribed before me this day of 20 Notary Public My Commission expires I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. *Signature of Individual By: Corporate Officer or Corporate Name (Mandatory) (Mandatory, if Applicable) **Social Security #(Voluntary) or Federal Identification Number * This license will not be issued unless this certification clause is signed by the applicant ** Your Social Security Number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non-filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Mass. G.L. c. 62C s. 49A. PARKING INFORMATION Is this a new of existing establishment? Yes No A new establishment will require parking approval (1 space per two seats) from the Planning Board (over eight spaces) If an existing establishment, are you proposing to increase the seating or occupancy? Yes No If yes, any increase in occupancy will require one space for each two seat increase in allowed seating. Also, the parking lot must be approved by the Planning Board. * What is the occupancy for this establishment How many parking spaces are there Where is the parking located Please provide a copy of any leases for parking spaces *You must contact the Department of Inspectional Services and they will determine the occupancy and the amount of parking required for this establishment. For further information please contact the Department of Inspectional Services 799-1198. Please sign this application and also have someone from the Department of Inspectional Services sign this form stating that they have reviewed the occupancy and parking lot requirements with you. Department of Inspectional Services Applicant Commonwealth of Massachusetts Alcoholic Beverages Control Commission 239 Causeway Street, First Floor Boston, MA 02114 STEVEN GROSSMAN KIM S. GAINSBORO, ESQ. TREASURER AND RECEIVER GENERAL CORI REQUEST FORM CHAIRMAN The Alcoholic Beverages Control Commission has been certified by the Criminal History Systems Board to access conviction and pending Criminal Offender Record Information. For the purpose of approving each shareholder, owner, licensee or applicant for an alcoholic beverages license, I understand that a criminal record check will be conducted on me, pursuant to the above. The information below is correct to the best of my knowledge. ABCC LICENSE INFORMATION ABCC NUMBER: LICENSEE NAME: CITY/TOWN: (IF EXISTING LICENSEE) APPLICANT INFORMATION LAST NAME: FIRST NAME: MIDDLE NAME: MAIDEN NAME OR ALIAS (IF APPLICABLE): PLACE OF BIRTH: DATE OF BIRTH: SSN: ID THEFT INDEX PIN (IF APPLICABLE): MOTHER'S MAIDEN NAME: DRIVER'S LICENSE #: STATE LIC. ISSUED: GENDER: HEIGHT: WEIGHT: EYE COLOR: CURRENT ADDRESS: CITY/TOWN: STATE: ZIP: FORMER ADDRESS: CITY/TOWN: STATE: ZIP: PRINT AND SIGN PRINTED NAME: APPLICANT/EMPLOYEE SIGNATURE: NOTARY INFORMATION On this before me, the undersigned notary public, personally appeared (name of document signer), proved to me through satisfactory evidence of identification, which were to be the person whose name is signed on the preceding or attached document, and acknowledged to me that (he) (she) signed it voluntarily for its stated purpose. NOTARY Print Form DIVISION USE ONLY REQUESTED BY: SIGNATURE OF CORI-AUTHORIZED EMPLOYEE The DCJI Identify Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft PIN Number by the DCJI. Certified agencies are required to provide all applicants the opportunity to include this information to ensure the accuracy of the CORI request process. ALL CORI request forms that include this field are required to be submitted to the DCJI via mail or by fax to (617) 660-4614.
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