ࡱ> ?A@%`  bjbjNN ,,, JJJJJJJ^B B B B N ^n     /111111$fhUJI " IIUJJ ijI"J J /I/JJ b 0da/rB k.0\@\\J, r!\}   UU   IIII^^^B ^^^B ^^^JJJJJJ  TOWN OF ANDOVER MASSACHUSETTS Human Resources GANDPS 36 Bartlet Street G Andover, MA 01810 978-623-8530  HYPERLINK "http://www.andoverma.gov" www.andoverma.gov CORI REQUEST FORM Andover Youth Services has been certified by the Criminal History Systems Board for access to all conviction data and pending court activity for school-based personnel. As a (prospective) employee/ volunteer for the position of _______________________ for Andover Youth Services, I understand that a criminal record check will be conducted for conviction and pending information only and that it will not necessarily disqualify me. The information below is correct to the best of my knowledge. ________________________________ Applicant / Employee Signature _________________________________________________________________________ Applicant / Employee Information (Please Print) ____________________ _____________________ ______________________ Last Name First Name Middle Name ____________________________ ______________________ Maiden Name/Alias (If Applicable) Place of Birth _______/_______/______ _____ - _____- _____ _______________________ Date of Birth Social Security Number Mothers Maiden Name (Requested but not required) Former Address: __________________________________________________________ _________________________________________________________________________ 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 C.O.R.I. 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