|To be used by organizations conducting CORI checks for employment, volunteer, subcontractor, licensing, and housing purposes.
Somerville-Cambridge Elder Services, Inc 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, 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 Somerville-Cambridge Elder Services, Inc. to submit a CORI check for my information to teh DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at any time by providing Somerville-Cambridge Elder Services, Inc. with written notice of my intent to withdraw consent to a CORI check.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:
Somerville-Cambridge Elder Services, Inc. may conduct subsequent CORI checks within one year of the date this Form was signed by me, provided, however, that Somerville-Cambridge Elder Services, Inc., must first provide me with written notice of this check.
By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of this Acknowledgement Form is true and accurate.