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Cape Cod and Islands Council, Inc. #224 � � Boy Scouts of America ,.�.�, °°'� Serving Cape Cod,Martha's Vineyard,and Nantucket Islands � � � � Agency Code: CGCCI � 172H j FE 172 Chapter 6,Sec.172H CORI REQUE5T FORM Cape Cod&Islands Council,Inc.,Boy Scouts of America,is requesting all the available criminal offender record infoimation(CORI) on the following individual fiom the Criminal History Systems Board pursuant to Chapter 6,Sec. 172H which mandates organizations primarily engaged in providing activities or prograins 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. A copy of the Cape Cod&Islands Council CORI policy is available on our website or may be obta.ined by contacting the Council Service Center at 508-362-4322. Volunteer Inforxnation(Please Print) � � Last Name First Name Middle Name �� Maiden Na�ne or Alias(If applicable) Place of Birth � , Date of Birth Social Security Number Mother's Maiden Name iCurrent and Former Addresses i i Sex: Height: ft. in. Weight: Eye Color: � State Driver's License Number: I This information was verified by reviewing the following form of government issued photographic identification: (Driver's License,Passport,etc.) Signatiue of Unit Committee Chairman I understand that any person who willfizlly requests,obtains or seeks to obtain criminal offeuder record infornzation(COI2I)under false pretenses,or who willfuily communicates or seeks to communicate CORI to any agency or person except in accordauce with the provisions of M.G.L.c.6, §§168 through 178B,ii�clusive,shall for each offense be fined not to exceed five thousand dollars ($5,000.00),or imprisoned in a jail or house of correction for up to one year,or both and/or may Ue ordered by the Criminal History Systems Board to pay civil fines not to exceed five hundred($500.00)for each willful violation. Please attach a copy of the applicant's photo ID to this form. Rev 4/23/2007 Tel. (508) 362-4322 247 WiT rozv Street Fax(508) 362-4323 www.scoutscapecod.org Yat�2outh Port�MA 02675