CORI APPLICANT REQUEST FORM
Winchester Basketball Association (WBA) has been certified by the Criminal  History Systems Board for
access to conviction and pending criminal case data. As an applicant/employee/volunteer for WBA, I
understand that a criminal record check will be conducted for conviction and pending criminal case
information only and that it will not necessarily disqualify me. WBA is requesting all the available criminal
offender information (CORI) on the following individual from the Criminal History Systems Board pursuant
to Chapter 6 S 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.
APPLICANT/EMPLOYEE/VOLUNTEER INFORMATION:
Middle Name** (or "NONE")
Last Name**:
 First Name**:
Maiden Name or Alias (if applicable)
 Place of Birth:
Date of Birth**(MM/DD/YY):
 Social Security Number(requested but not required):
Theft Index PIN* (if applicable, not required)
Maiden Name or Alias (if applicable):
CURRENT ADDRESS:
Current Street Address:**:
Current Town of Residence**:
 Zip Code**:
Sex:
Male
Female
Weight:
Height:
 Eye Color:
Driver's License Number**:
State Where Driver's License Issued**:
* The CHSB Identity Theft Index PIN Number is to be completed by those applicants that have been
issued an Identity Theft Index PIN Number by the CHSB. Certified agencies are required to provide all
applicants the opportunity to include this information to ensure the accuracy of the CORI request
process. All CORI request forms that include this field are required to be submitted to the CHSB via
mail or by Fax to 617-660-4614.
I hereby agree that all information submitted here electronically, is accurate to the best
of my knowledge, and submittal of this electronic form confirms this acknowledgement.