To be used by organizations conducting CORI checks for employment, volunteer, licensing purposes. Hellenic
American Academy is registered under the provision of M.G.L. C.6, & 172 to receive CORI for the purpose of
screening current and otherwise qualified prospective employees, subcontractors, volunteers, and license
applicants.

As a prospective or current employee, subcontractor, volunteer, or license applicant, I understand that a CORI
check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide
permission to Hellenic American Academy 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 Hellenic American Academy with written notice of my intent to withdraw consent to a CORI
check. For employment, volunteer, and licensing purposes only: The Hellenic American Academy may
conduct subsequent CORI checks within one year of the date this form was signed by me provided, however,
that Hellenic American Academy must first provide me with written notice of this check.

By signing below, I provide my consent to a CORI check and acknowledge that the information provided of this
acknowledgment form is true and accurate.