CORI Request From by jey14242

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                                     CORI REQUEST FORM

As a (prospective) volunteer for a position with the City of Methuen’s Department of Emergency
Management, I understand that a criminal record check will be conducted for 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.

______________________________
(Prospective) Volunteer Signature


PERSONAL INFORMATION OF VOLUNTEER:


___________________________________________________________________
LAST NAME               FIRST NAME              MIDDLE NAME

___________________________________________________________________
MADIAN NAME OR ALIAS (IF APPLICABLE)

_______________        __________________________            ___________________
DATE OF BIRTH          SOCIAL SECURITY NUMBER                PHONE NUMBER


ADDRESS:

___________________________________________________________________
HOUSE NUMBER                  STREET

___________________________________________________________________
CITY                          STATE                   ZIP CODE

If you have lived at your current address for less than five years, please provide previous address:

___________________________________________________________________
HOUSE NUMBER                  STREET

___________________________________________________________________
CITY                          STATE                   ZIP CODE




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