Harvard Police Department
40 Ayer Road
Harvard, MA 01451
(978) 456-1212
Fax: (978) 456-8313

The Commonwealth of Massachusetts
Executive Office of Public Safety
Criminal History Systems Board
Criminal Justice Information System
200 Arlington Street Suite 2200
Chelsea, Massachusetts 02150
Phone: (617) 660-4600

Personal Criminal Record Request Form

If you want a copy of your own record, use this form and return it to the
address above with a self-addressed, stamped envelope. You will receive a
response by mail. YOU MUST HAVE YOUR SIGNATURE NOTARIZED BY A NOTARY PUBLIC
BEFORE YOUR REQUEST CAN BE PROCESSED.  No walk-in service is available.
(PLEASE PRINT)

** Please check here if you need this for immigration/adoption purposes [  ]

Name:                   _____________________________________________________

Maiden Name/Alias:      _____________________________________________________

Date of Birth:          ________________________________________ (mm/dd/yyyy)

Social Security Number: _____________________________________________________

Address:                _____________________________________________________

Town/State/Zip Code:    _____________________________________________________

Mother's Maiden Name:   _____________________________________________________

I swear that I am the above-name person under the pains a penalties of
perjury, and further acknowledge that I am aware that Massachusetts law
prohibits a person from requesting or requiring me to produce a copy of my
own record, unless so authorized by the Criminal History Systems Board.

Signature of Applicant: _______________________________ Date: _______________

AUTHENTICATION OF SIGNATURE BY NOTARY PUBLIC

___________________, ss.
County

Then appeared before me the above-named, ____________________________________
and swore the statements made herein to be true.

Dated: ________________ Notary Public: ______________________________________

My Commission Expires: ______________________________________________________



OBTAINING YOUR OWN CRIMINAL RECORD

For a copy of your own criminal record, this form must be notarized and
mailed to our office with a self-addressed, stamped envelope.

Please be advised that if you have requested a copy of your own criminal
record for the purpose of employment, the most recent amendment to the
C.O.R.I. law states that:

        "...except as authorized by this chapter it shall be unlawful to
        request or require a person to provide a copy of his criminal
        offender record information (C.O.R.I.)." (Massachusetts General Laws,
        Chapter 6, Section 172)

In order for any person, governmental agency or business to access a person's
criminal record , the must make application to this agency, be certified by
the Criminal History Systems Board and have your written approval. The
general public may request a person's criminal record under the public access
law. This law allows conviction information on persons who have recently been
involved with the criminal justice system following a conviction. This
information is available to anyone, including an employer, without the
consent of the person whose record is being obtained.

Your notarized form should include a self-addressed, stamped envelope and be
mailed to:

         CRIMINAL HISTORY SYSTEMS BOARD
         200 Arlington Street
         Suite 2200, Room 2111
         Chelsea, MA 02150