Boston Nanny Centre - BOSNC/$
7. CORI Request Form

This is a Printable Form Only! Click Here to Print this Form fill it out and send it back to the
Boston Nanny Centre (135 Selwyn Road, Newton, MA 02461)

Boston Nanny Centre - BOSNC/$
135 Selwyn Road, Newton, MA 02461 z

CORI REQUEST FORM

Boston Nanny Centre has been certified by the Criminal History Systems Board for access to conviction and pending criminal case data. As an applicant/employee for _______________, 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.

___________________________________________
Applicant/Employee Signature

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 (Requested but not required) MOTHER'S MAIDEN NAME

FORMER ADDRESS: _____________________________________________________________
______________________________________________________________________________

______ FEET _____ INCHES ____ _______ LBS. __________
SEX HEIGHT WEIGHT EYE COLOR

STATE DRIVER'S LICENSE NUMBER:__________________________________________

*** THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE FOLLOWING FORM OF GOVERNMENT
ISSUED PHOTOGRAPHIC IDENTIFICATION:_________________________________________________

REQUESTED BY: ____________________________________________
SIGNATURE OF CORI AUTHORIZED EMPLOYEE OF THE BOSTON NANNY CENTRE

CHSB USE ONLY
RECORD ATTACHED: ________ NO RECORD: _______
Boston Nanny Centre || 135 Selwyn Road Newton, MA 02461 (617) 527-0114 Fax (617) 969-8401