Acknowledgement Form

The Town of Wakefield 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 and current licensees.

As a prospective or current employee, subcontractor, volunteer, license applicant or current licensee, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to the Town of Wakefield to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my submission. I understand that within this one year period of time the Town of Wakefield may conduct subsequent CORI checks for my personal information. I may withdraw this authorization at any time by providing the Town of Wakefield with written notice of my intent to withdraw consent to a CORI check.

I understand that the information provided will also be used to perform a SORI check with the USDOJ, and requires me to submit a copy of mydriver's license and birth certificate. Please complete the form below.

First Name *

Middle Name *

Last Name *

Email *

Date of birth *

Month

Day

Year

Current Street Address: *

City *

State *

Zip Code *

Requesting department: *

Position for which you are requesting: *

Upload Copy of Birth Certificate *

Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png bmp pdf.

Upload Copy of Driver's License *

Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png pdf.

Signature *

By entering my name above and submitting this application, I provide my consent to a CORI check and affirm that the information provided to process the CORI check is true and accurate.

Leave this field blank

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Acknowledgement Form