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ADDA-E-3

ADDA-E-3: C.O.R.I. REQUEST FORM

[AGENCY CODE] [FEE CODE]

COMPANY LETTERHEAD (The above code must remain visible)

CORI REQUEST FORM

[AGENCY NAME] has been certified by the Criminal History Systems Board for access to... [INSERT SHORT FORM OF YOUR AGENCY’S CERTIFICATION. THIS INFORMATION IS AVAILABLE ON YOUR CURRENT REQUEST FORM]

APPLICANT/EMPLOYEE INFORMATION (PLEASE PRINT)

LAST NAME FIRST NAME MIDDLE NAME

MAIDEN NAME OR ALIAS (IF APPLICABLE) PLACE OF BIRTH

DATE OF BIRTH SOCIAL SECURITY NUMBER MOTHER’S MAIDEN NAME (Requested but not required)

FORMER ADDRESSES:

SEX: HEIGHT: ft .in. WEIGHT: EYE COLOR:

STATE DRIVER’S LICENSE NUMBER:

*** THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE FOLLOWING FORM OF GOVERNMENT ISSUED PHOTOGRAPHIC IDENTIFICATION:

REQUESTED BY: SIGNATURE OF CORI AUTHORIZED EMPLOYEE

SOURCE: MASC 2005

Adopted on: September 27, 2007

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