Abcc Cori Form – Fill Out and Use This PDF

Commonwealth of Massachusetts

Alcoholic Beverages Control Commission

239 Causeway Street, First Floor

Boston, MA 02114

The Alcoholic Beverages Control Commission has been certified by the Criminal History Systems Board to access conviction and pending Criminal Offender Record Information. For the purpose of approving each shareholder, owner, licensee or applicant for an alcoholic beverages license, I understand that a criminal record check will be conducted on me, pursuant to the above. The information below is correct to the best of my knowledge.

ABCC LICENSE INFORMATION

ABCC NUMBER:		LICENSEE NAME:		CITY/TOWN:
(IF EXISTING LICENSEE)
APPLICANT INFORMATION
LAST NAME:		FIRST NAME:		MIDDLE NAME:
MAIDEN NAME OR ALIAS (IF APPLICABLE):			PLACE OF BIRTH:
DATE OF BIRTH:		SSN:	ID THEFT INDEX PIN (IF APPLICABLE):
MOTHER'S MAIDEN NAME:		DRIVER'S LICENSE #:		STATE LIC. ISSUED:
GENDER:	HEIGHT:		WEIGHT:	EYE COLOR:
CURRENT ADDRESS:
CITY/TOWN:		STATE:	ZIP:
FORMER ADDRESS:
CITY/TOWN:		STATE:	ZIP:
PRINT AND SIGN
PRINTED NAME:		APPLICANT/EMPLOYEE SIGNATURE:

NOTARY INFORMATION

On this before me, the undersigned notary public, personally appeared

(name of document signer), proved to me through satisfactory evidence of identification, which were

to be the person whose name is signed on the preceding or attached document, and acknowledged to me that (he) (she) signed it voluntarily for its stated purpose.

NOTARY

DIVISION USE ONLY

REQUESTED BY:

SIGNATURE OF CORI-AUTHORIZED EMPLOYEE

The DCJI Identify Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft PIN Number by the DCJI. Certified agencies are required to provide all applicants the opportunity to include this information to ensure the accuracy of the CORI request process. ALL CORI request forms that include this field are required to be submitted to the DCJI via mail or by fax to (617) 660-4614.