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3 years ago

Board of State Examiners of Plumbers and Gas Fitters ... - PSI

Board of State Examiners of Plumbers and Gas Fitters ... - PSI

Notice

Notice and Instruction sheet for CORI Acknowledgement Form Dear Licensee: If your license application indicates that you checked “Yes” in response to the question regarding the existence of any criminal convictions. The Board will need to review your Criminal Offender Record Information (CORI) record before proceeding further with the processing of your application. As noted on your application form the Board is certified by the state’s Criminal History Systems Board to receive from it and review criminal conviction and pending criminal case information. In order to do so, the Criminal History Systems Board requires that the licensee be placed on notice that a CORI check will be performed. Please complete the attached CORI notification acknowledgement form and return it with this letter and your application immediately to the PSI. Any delay in completing and returning this form will delay the processing of your license application. Upon receipt of this acknowledgment form, the Board will request and review your criminal record. If it is necessary for you to appear before the Board to answer questions about your CORI data, you will be notified in advance. If it is not necessary for you to appear before the Board after your criminal record is requested and reviewed, the Board will continue processing your application for licensure. Sincerely, Joseph A. Peluso Executive Director Board of the Examiners of Plumbers and Gas Fitters Enclosure

Commonwealth of Massachusetts OFFICE OF CONSUMER AFFAIRS DIVISION OF PROFESSIONAL LICENSURE 1000 Washington St., 7 th Floor Boston, Massachusetts 02118 . CORI ACKNOWLEDGEMENT FORM I acknowledge that, The Division of Professional Licensure has been certified by the Criminal History Systems Board [ID# MAREG G] to access data about my convictions and pending criminal case data. As an applicant/licensee for _________________________, I understand that a criminal record check will be Plumbing, Gasfitting, Electrical, other conducted to review applicable convictions and pending criminal case information only and that it will not necessarily disqualify me. The information below is correct to the best of my knowledge. _____________________________________________ Applicant/Licensee Signature APPLICANT/LICENSEE INFORMATION (PLEASE PRINT) _______________________________ ___________________________ __________________ LAST NAME FIRST NAME MIDDLE NAME ___________________________________________ MAIDEN NAME OR ALIAS (IF APPLICABLE) DATE OF BIRTH: ____________________ SOCIAL SECURITY NUMBER_________-_________-_________ (Mandatory) ADDRESS: ______________________________________________________________________________ ___________________________________________________________________________ CHSB USE ONLY RECORD ATTACHED:________ NO RECORD:__________

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