Chapter 6, S 172H CORI Request Form

Sachem Youth Baseball/Softball Association (SYBS) has been certified by the Criminal History Systems Board for access to conviction and pending criminal case data. As an applicant/employee/volunteer for SYBS, 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. SYBS is requesting all the available criminal offender information (CORI) on the following individual from the Criminal History Systems Board pursuant to Chapter 6 S 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.
Volunteer Information

 Last Name**:
 
 First Name**:
 
 Middle Name (if none, enter "None")**:
 
 Maiden Name or Alias (If Applicable):
 
 Date of Birth (mm/dd/yyyy)**:
 
Full number optional
Last 6 digits required**:
 Social Security Number -
 
 Street Address**:
 
 Town**:
 
 Zip Code**:
 
 Theft PIN Index (if applicable)*:
 
 * The CHSB Identity Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft Index PIN Number by the CHSB. Certified agencies are required to provide all applicants the opportunity to include this information to ensure the accuracy of the CORI request process.
 
 ** Required Field
 
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