Do not complete until you are notified that 
you are the final candidate for a position.

NOTE:  This form is provided as guidance to EOHHS human service providers subject to 101 CMR 15.00  who choose to ask applicants, as part of their hiring process, to self-report any criminal history.  Such a self report question is OPTIONAL.  Where a CORI check is determined necessary, some employers choose to both ask applicants directly and conduct a CORI check.  

Note that, as required in 110 CMR 15.06, any questions regarding criminal history must be held until the end of the hiring process and introduced only when an applicant has been determined otherwise qualified for the position and given a conditional offer of employment subject to consideration of any criminal record.    Any inquiry made must be comply with M.G.L. c.151B, §4, para 9.   

This form is provided as informal guidance only.   It is not intended as legal advice.   Any use or adaptation of this form is at the discretion of a Hiring Authority.

Criminal Records Disclosure Form

Have you been convicted of a felony? YES      NO     (Conviction will not necessarily disqualify an applicant from employment.)    
If yes, please explain.*  
________________________________________________________________________________________________________________________________________

Have you been convicted of a misdemeanor other than a first misdemeanor conviction for drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace within the last 5 years? YES      NO     (Conviction will not necessarily disqualify an applicant from employment.)    If yes, please explain.*  ________________________________________________________________________________________________________________________________________

*  “An applicant for employment with a sealed record on file with the Commissioner of Probation may answer ‘no record’ with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, any applicant for employment may answer ‘no record’ with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution.” 

MGL Ch. 276, Section 100A.

I certify under the pains and penalty of perjury that all statements made by me on this form are true and complete to the best of my knowledge and that I have withheld nothing, which, if disclosed, would affect this application unfavorably.  I understand that any false statements, omissions or answers made by me on this application can result in my immediate termination.

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		Signature of Applicant						Date

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		Printed Name