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CHAPTER 6, § 172 C CORI REQUEST FORM

Eden Healthcare Services has been certified by the criminal History Systems Board to all the available criminal offender record information on the following individual from the Criminal History Systems Board pursuant to Chapter 6, § 172 C that mandates agencies which employ or accept as a volunteer or refer for employment any individual who will provide care , treatment, education, training, transportation, delivery of meals, instruction, counseling, supervision, recreation, or other services in a home or in a community based setting for any elderly person or disabled person or who will have and direct or indirect contact with such elderly or disabled persons or access to such person’s files shall obtain all available CORI from the Criminal History Systems Board prior to employing such individual, accepting such individual as a volunteer or referring such individual for employment.

APPLICANT/EMPLOYEE SIGNATURE (unless otherwise preempted by law)

Signature:

LAST NAME:

FIRST NAME:

MIDDLE NAME:

MAIDEN NAME OR ALIAS (IF APPLICABLE) :

PLACE OF BIRTH:

DATE OF BIRTH:

SOCIAL SECURITY NUMBER:

ID theft Index PIN:

MOTHER’S MAIDEN NAME:

CURRENT ADDRESSES:

FORMER ADDRESS:

SEX:

HEIGHT:

WEIGHT:

EYE COLOR:

STATE DRIVER’S LICENSE NUMBER:

* THE INFORMATION WAS VERIFIED WITH THE FOLLOWING FORM OF GOVERNMENT ISSUED

PHOTOGRAPHIC IDENTIFICATION:

SIGNATURE OF CORI AUTHORIZED EMPLOYEE

NAME:

The CHSB Identify Theft Index PIN is to be completed by those applicants that have been issued an Identify Theft Index PIN Number by the CHSB. Certified agencies are required to provide all applicants the opportunity to include this information to ensure the accuracy of the CORI request process.
All CORI request forms that include this field are required to be submitted to the CHSB via mail

Employment Application

REFERAL INFORMATION

EMERGENCY CONTACT INFORMATION - Please Print Clearly

Employment History - Please begin with your most recent or current place of employment.

Military Service

Education

Licenses and Certifications

Criminal History

CHAPTER 6, § 172 C CORI REQUEST FORM

APPLICANT/EMPLOYEE SIGNATURE (unless otherwise preempted by law)

REFERENCE FORM #1

REFERENCE FORM #2

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