Access to Care
When You Need It Most

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PERSONAL DATA:

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Are you legally authorized to work in the United States?*

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Are you over 18 years of age?*

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If no, are you over 16 years of age?

YesNo

CORI (Criminal Offender Record Information) Request Form

M.G.L.c.6,  172E CORI REQUEST FORM Fountains at Mill Cove is requesting all the available criminal offender record information on the below named individual from the Criminal History Systems Board pursuant to M.G.L.c.6,  172E, which mandates that long-term care facilities complete background checks on current or prospective employees who will provide direct personal care and treatment to residents of said facility.

CHAPTER 6,  172C CORI REQUEST FORM Fountains at Mill Cove is requesting all the available criminal offender record information on the following individual from the Criminal History Systems Board pursuant to Chapter 6 172C that mandates agencies which employ or accept as a volunteer or refer for employment any individual who will provide care, treatment, education, training, transportation, delivery of meals, instruction, counseling, supervision, recreation or other services in a home or in a community based setting for any elderly person or disabled person or who will have any direct or indirect contact with such elderly or disabled persons or access to such person’s files shall obtain all available CORI from the Criminal History Systems Board prior to employing such individual, accepting such individual as a volunteer or referring such individual for employment.

AGREEMENT: (Please read the following statement carefully)

I certify that all information on this application and any other material provided by me is true and complete. I agree that falsified information, misrepresentations or omissions on this application, or any accompanying resume or other materials will disqualify me from consideration for employment and will be considered justification for dismissal whenever discovered.

Unless otherwise noted, I authorize this Company or its agent to investigate and/or verify all information in this application, including contacting all persons, schools, current employer (if applicable), previous employers and other individuals or entities named herein (and those named on accompanying resume if any). I hereby authorize my former employers and other third parties named on this application to release information pertaining to my work record, habits and performances. In doing so, I hereby release them and Fountains at Mill Cove and its agents from all liability which may flow from the release of such information.

I understand that if I am hired my employment will be on an at-will basis, for no definite term. As such, I understand that I will enjoy the right to terminate my employment at any time, and that Fountains at Mill Cove will similarly enjoy the right to terminate my employment, at any time, with or without cause. This status can only be modified by a written document setting forth such modification, signed by both me and an authorized representative of Fountains at Mill Cove. I further acknowledge that I am expected to abide by all Company rules, regulations, and policies, written or unwritten, but that such rules, regulations and policies do not create a contract between me and the Company or otherwise restrict the right of either party to terminate the employment relationship.