The Commonwealth of Massachusetts
	Executive Office of Health and Human Services
	Department of Public Health
	Bureau of Health Professions Licensure
	Board of Registration in Dentistry
	239 Causeway Street, Suite 500, Boston, MA 02114
	CHARLES D. BAKER	MARYLOU SUDDERS
	Governor	Tel:  617-973-0971	Secretary
	KARYN E. POLITO	Fax: 617-973-0982	MONICA BHAREL, MD, MPH
	Lieutenant Governor	www.mass.gov/dph/boards/dn	Commissioner
	
	CRIMINAL OFFENDER RECORD INFORMATION (CORI)
	ACKNOWLEDGEMENT FORM
	
	TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT, 
	VOLUNTEER, SUBCONTRACTOR, LICENSING, AND HOUSING PURPOSES.
	
	The Board of Registration in Dentistry is registered under the provisions of M.G.L. c. 6, § 172 to receive 
	CORI for the purpose of screening current and otherwise qualified license applicants and current licensees.
	As a prospective or current license applicant or current licensee, I understand that a CORI check will be 
	submitted for my personal information to the Department of Criminal Justice Information Systems (DCJIS). I 
	hereby acknowledge and provide permission to the Board of Registration in Dentistry to submit a CORI check
	 for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I may 
	withdraw this authorization at any time by providing written notice of my intent to withdraw consent to a CORI
	 check.
	I also understand that the Board of Registration in Dentistry may conduct subsequent CORI checks within 
	one year of the date this Form was signed by me.
	
	By signing below, I provide my consent to a CORI check and acknowledge that the information provided on 
	Page 2 of this Acknowledgement Form is true and accurate. 

	___________________________________                      
	SIGNATURE
	
	__________________________________ 
	DATE   
	
	NOTE:  The Board of Registration in Dentistry cannot accept this form unless it is either (1) signed in person 
	at the Board's offices in the presence of a DHPL employee who has verified the applicant's identity through 
	acceptable identification, or (2) signed in the presence of a notary public who has likewise verified identity and 
	then mailed or hand-delivered to the Board's offices at the address set forth above.
	January 2018	Page 1 of 2

	CRIMINAL OFFENDER RECORD INFORMATION (CORI)
	ACKNOWLEDGEMENT FORM
	
	SUBJECT INFORMATION: (An asterisk (*) denotes a required field)
	
	_________________________________________________________________________ 
	*Last Name                        *First Name                          Middle Name                   Suffix 
	
	_______________________________ 
	Maiden Name (or other name(s) by which you have been known) 
	
	________________                                       ________________
	Date of Birth                                                 Place of Birth 
	
	Last Six Digits of Your Social Security Number: _______-_________ 
	
	Sex: ____      Height: ___ft. __ in.      Eye Color: _________                 Race: __________ 
	
	Driver’s License or ID Number: _____________________                   State of Issue: ________ 

	____________________________________                 ____________________________________ 
	Mother’s Full Name  (Mother's Maiden Name)                    Father’s Full Name 
	
	Current and Former Addresses: 
	
	______________________________________________________________________________ 
	Street Number & Name                      City/Town                        State              Zip 
	
	______________________________________________________________________________ 
	Street Number & Name                      City/Town                        State              Zip 
	
	______________________________________________________________________________ 
	
	The identity of the subject of this acknowledgement form was verified by reviewing the following form(s) of 
	government-issued identification: 
	
	                         _______________________________________________________
	
	                         _______________________________________________________

	VERIFIED BY:  ________________________________________________       ON ____________
	                        Name of Verifying DHPL Employee or Notary Public (Please Print)             Date
	
	                          ________________________________________________
	                             Signature of Verifying DHPL Employee or Notary Public

	January 2018	Page 2 of 2