CORI Form

 

Program: WH Lacrosse Club

 CHAPTER 6, §172H CORI REQUEST FORM 

US Lacrosse, Inc. is requesting all the available criminal offender record information (CORI) on the following individual from the Criminal History Systems Board pursuant to Chapter 6, §172H which mandates organizations primarily engaged in providing activities or programs to children 18 years of age or less that accepts volunteers, to obtain all CORI regarding volunteers prior to accepting any person as a volunteer. 

VOLUNTEER INFORMATION (please type or print)

 _____________________    _________________       ___________________ 

LAST NAME         FIRST NAMEMIDDLE NAME 

MAIDEN NAME OR ALIAS (IF APPLICABLE)__ _____________________

PLACE OF BIRTH: _____________________________ 

DATE OF BIRTH: ______-______-_________

SOCIAL SECURITY NUMBER  _________-______-_________ 

 

CURRENT ADDRESS:________________________________________

 ____________________________________________________________ 

 

SEX: ____ HEIGHT:____ft.____in. WEIGHT:_____ EYE COLOR:_____ 

DRIVER'S LICENSE NUMBER:__________________ STATE:________ 

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

 ______ DRIVERS LICENSE 

______ OTHER: ________________________ _________________________ (Specify type) Number) 

REQUESTED BY: ____________________________________________ 

SIGNATURE OF CORI AUTHORIZED EMPLOYEE DATE