NVSUA
								172H
								FE2093

		CHAPTER 6, 172H CORI REQUEST FORM
    
NVSUA 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 staff and volunteers. 
________________________________________________________________________
		APPLICANT INFORMATION (PLEASE PRINT or TYPE) 

	 
__________________________	_____________________	______________
LAST NAME			    FIRST NAME		  MIDDLE NAME


____________________________________ 	________________________
MAIDEN NAME OR ALIAS (IF APPLICABLE)	     PLACE OF BIRTH


________________     ________-_______-_________     _________________________
DATE OF BIRTH          SOCIAL SECURITY NUMBER     	ID Theft Index PIN *
			     (Requested, not required)	(if applicable)

___________________________
MOTHER’S MAIDEN NAME                                   

CURRENT AND FORMER ADDRESSES: 

_______________________________________________________________

_______________________________________________________________


SEX: ____     HEIGHT: ___ft. __in.		WEIGHT:_______ EYE COLOR:______


STATE DRIVER’S LICENSE NUMBER: ______________________________________
					(Include state of issue)


***THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE 
FOLLOWING FORM OF GOVERNMENT ISSUED PHOTOGRAPHIC 
IDENTIFICATION:
		    ______________________________________.


REQUESTED BY: _____________________________________________
SIGNATURE OF CORI AUTHORIZED EMPLOYEE

*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.