|
285 Old Westport Road No Dartmouth MA 02747-2300 |
College of Nursing Tel # 508-999-8586 Fax # 508-999-9127 |
GUMASD
G
CORI REQUEST FORM
University of Massachusetts - Dartmouth, College of Nursing has been certified by the Criminal History Systems Board for access to conviction and pending criminal case data. As a (prospective) employee/volunteer for the position of clinical student, 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. The information below is correct to the best of my knowledge.
--------------------------------------------------------------------------------------------------------------------------
STUDENT 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
Last Updated On: 11/1/06
