ࡱ> =?<` bjbj .T T T T h +l III$hbf|Iff 'f  ff6 0'T @0+a(Raa I|sdIIIzIII+ffffT T    BRIDGEWATER RECREATION COMMISSION Town Hall Building - 64 Central Square Bridgewater, MA 02324 508.697.8020 Fax: 508.697.4611 E-mail:  HYPERLINK "mailto:recreation@bridgewaterma.org" recreation@bridgewaterma.org Website: www.bridgewaterma.org/Government/Recreation James P. Campbell Chairman Gina Guasconi Vice-Chairman Thomas P. Arrighi Daniel Buron George Rogers Charles L. Simonds Superintendent BWREC 172H G CHAPTER 6, (172H CORI REQUEST FORM Bridgewater Recreation Commission 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 SIGNATURE VOLUNTEER INFORMATION: PLEASE PRINT _________________________ _______________________ __________________ LAST NAME (Please Print) FIRST NAME MIDDLE NAME ______________________________________________ ________________________ MAIDEN NAME OR ALIAS (IF APPLICABLE) PLACE OF BIRTH _______________ _______-_______-________ _______________________ DATE OF BIRTH SOCIAL SECURITY NUMBER MOTHERS MAIDEN NAME (Requested but not required) CURRENT AND FORMER ADDRESSES: _________________________________________________ ___________________________________________________________ ___________________________________________________________ SEX: __________ HEIGHT: ___ft.___in. WEIGHT:_________ EYE COLOR:______ STATE DRIVERS LICENSE NUMBER: ____________________________________ ***THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE FOLLOWING FORM OF GOVERNMENT ISSUED PHOTOGRAPHIC IDENTIFICATION: ______________________________________________________ REQUESTED BY: ______________________________________________________ SIGNATURE OF CORI AUTHORIZED EMPLOYEE: Thomas P. Arrighi, Bridgewater Recreation, or Charles L. 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