I acknowledge that I have read and fully understand this application, including the above statements and the authorization for a background investigation.
TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT, VOLUNTEER, SUBCONTRACTOR, LICENSING, AND HOUSING PURPOSES.
The Suffolk County Sheriff’s Department 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, Jr. Cadets, 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 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 the Suffolk County Sheriff’s Department with a written notice of my intent to withdraw consent to a CORI check.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:
The Suffolk County Sheriff’s Department may conduct subsequent CORI checks within one year of the date this form was signed by me provided, however, that the Suffolk County Sheriff’s Department must first provide me with written notice of this check.
I hereby release, discharge, and exonerate the Suffolk County Sheriff, his agents and representatives, and any person furnishing information, from any and all liability of every nature and kind rising out of the furnishing, inspection, or withholding of such documents, records, and other information, as well as for the investigation made by or on behalf of the Suffolk County Sheriff.
By signing below, I provide my consent to a CORI check and acknowledge that the information provided on
the next page of this acknowledgement form is true and accurate.