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2. Print Name of Applicant:
4. as a:

   1. Prospective or current employee
   2. Volunteer or Intern:
6. Position applying for:

   1. Professional Licensing Apllicant
   2. Subcontractor
   3. Current Licensee
   4. Applicant for the leasing of Town-owned property

8. I understand that a CORI check will be submitted for my personal information to the Department of Criminal Justice Information Services (DCJIS).

   I hereby acknowledge and provide permission to the Town of Stoneham 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 Town of Stoneham with written notice of my intent to withdraw consent to a CORI check.

   I understand that the Town of Stoneham may conduct subsequent CORI checks within one year of the date this form was signed by me; however, prior to conducting a subsequent CORI check(s), the Town of Stoneham must first provide me with a written notice.

   By signing below, I am providing my consent to a CORI check and acknowledge that the information provided on page two of this Acknowledgement Form is true and accurate.

10. Applicant's Signature
11. Date Signed
13. Last Name
14. First Name
15. Middle Name
16. Suffix
18. Your Maiden Name
19. List any other name(s) by which you have been known
21. Date of Birth (Month/Day/Year)
22. Place of Birth (City and State)
23. Sex:

    1. Male
    2. Female
25. The last 6 numbers of your Social Security #:
26. Race:
28. Mother's Full Maiden Name:
29. Father's Full Name
31. Your Current Address:
33. Street Number & Name
35. City/Town
36. State
37. Zip
39. Your Former Address:
41. Street Number & Name
43. City/Town
44. State
45. Zip
47. Your Former Address:
49. Street Number & Name
51. City/Town
52. State
53. Zip
55. Your Former Address:
57. Street Number & Name
59. City/Town
60. State
61. Zip
63. If you are a victim of identity theft, please include your ID theft index PIN Number:
65. Verification of acceptable forms of Government issued identification (This Section to be completed by the verifying Town Employee)
67. Applicant's Height:
68. Feet:
69. Inches
70. Eye Color:
72. State issued Driver's License:
73. State of Issue:
74. License #
75. Expiration:
77. State issued ID with photograph:
78. State of Issue
79. ID #
80. Expiration
82. A Valid Passport:
83. Country of Issue
84. Passport #
85. Expiration:
87. I have verified the applicant's identity by examining one of the above acceptable forms of government-issued identification. A photocopy of document is attached.
89. Signature of Verifying Town Employee
90. Date:
92. Signature of Authorized CORI Official
93. Date:
Leave This Blank:


95. 1. Receive an email copy of this form.
96. Email address

    This field is not part of the form submission.

97. Submit

* indicates a required field