CORI Form

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2007-08 Budget
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CORI Form

Hamilton-Wenham
Youth Basketball
Chris Fibbe, President
cfibbe@hwybb.org

Payment Address &
Registration Info:
Beth Loeper, Treasurer
15 Ricker Circle
Hamilton, MA 01982
beth@hwybb.org

WebMaster/Consultant:
Doug Lindland
Tel: 978-468-2040
Fax: 978.468.6030
doug@hwybb.org

Hamilton Wenham Youth Basketball - Chapter 6, 172H CORI REQUEST FORM

Hamilton-Wenham Youth Basketball is requesting all the available criminal offender record information (CORI) on the following individual from the Criminal History Systems Board pursuant to Chapter 6, 172H which mandates organizations primarily engaged in providing activities or programs to children 18 years of age or less that accepts volunteers, to obtain all CORI regarding volunteers prior to accepting any person as a volunteer.

IT IS NECESSARY TO SEND A COPY OF THE IDENTIFICATION YOU USED TO FILL OUT THE CORI FORM to:

Beth Loeper
15 Ricker Circle
S. Hamilton, MA 01982

or fax to 978-468-6030

Please fill out the form below:

* indicates a REQUIRED field. Please be sure to complete all required fields or the form will not go through.

*First Name:
*Last Name:
Middle Name:
Maiden Name/Alias: (If applicable)
*Place of birth:
*Date of birth: (mm/dd/yyyy)
Social Security Number: (requested not required)
*Mother's Maiden Name:
*Current Address:
*Former Address 1:
Former Address 2:
*E-Mail:
*Sex:
*Height: (ft, in, 5'9")
*Weight:
*Eye Color:
*State Driver's License #:

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Site by Doug E. Lindland