Volunteer Background Check Authorization Form PART I: CRIMINAL OFFENDER RECORD INFORMATION (CORI) ACKNOWLEDGEMENT FORM The West End House Boys & Girls Club of Allston-Brighton (WEH) is registered under the provisions of M.G.L. c. 6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of housing. As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, or applicant for the rental or lease of housing, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to WEH 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 WEH with written notice of my intent to withdraw consent to a CORI check. FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY: WEH may conduct subsequent CORI checks within one year of the date this Form was signed by me provided, however, that WEH must first provide me with written notice of this check.CONSENT* By checking this box and entering my name under SIGNATURE, I provide my consent to a CORI check and acknowledge that the information provided below on this Acknowledgement Form is true and accurate.Signature* To sign, type your nameDate Signed* MM slash DD slash YYYY Name* First Middle Last Suffix Maiden Name or any other name by which you have been known (if applicable) Date of Birth (mm/dd/yyyy)*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Place of Birth (City, State, Country)* Gender* Race* Eye Color* Height (feet, inches)* Father's Name* First Middle Last Mother's Name First Middle Last Maiden Current Address* Street Address Address Line 2 City State ZIP / Postal Code Former Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Your Phone Number*Driver's License or ID#* PART II: LEXISNEXIS DISCLOSURE AND AUTHORIZATION Important: Please Read Carefully Before Signing Authorization Disclosure Regarding Background Investigation The West End House Boys & Girls Club (WEH) may obtain information about you for employment/volunteer purposes from a third-party consumer reporting agency. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. The scope of this notice and authorization is all-encompassing, allowing WEH to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment/volunteerism to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report. Acknowledgement and Authorization I acknowledge receipt of the Disclosure Regarding Background Investigation and certify that I have read and understand the document. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by WEH at any time after receipt of this authorization and throughout my employment/volunteerism, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state of federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by LexisNexis Screening Solutions Inc. on behalf of WEH. I agree that a facsimile (“fax”), electronic, or photographic copy of this Authorization shall be as valid as the original.CONSENT* By checking this box I indicate that I understand that a request will be made for Sex Offender Registry Information (SORI). This is part of the background check for employment and/or volunteerism at WEH.Signature* Type your name to sign
