POLICE> OFFICE OF THE POLICE
If you would like a copy of your own Massachusetts criminal record, complete this form, sign it in front of a notary public, and mail it, along with a self-addressed stamped envelope to this agency. Walk-in service is not available. If you are incarcerated and a notary public is not available, have an official of the correctional facility endorse same. This agency's mailing address is: Criminal History Systems Board, 200 Arlington Street, Suite 2200, Chelsea, MA 02150 ATTN: CORI Unit.
Please be advised that it is unlawful to request or require a person to provide a copy of his criminal offender record information, except as authorized by the Criminal History Systems Board, as per M.G.L.c.6§172.
Please check the appropriate box if this request is for immigration [ ] or adoption [ ] purposes.
I hereby swear, under the pains and penalties of perjury, that the information I have provided above is true, and to the best of my knowledge and belief.
AUTHENTICATION OF SIGNATURE BY NOTARY PUBLIC OR CORRECTIONAL FACILTIY
The above named____________________________, appeared
before me, the undersigned authority, this_____________day of
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Office of the Mayor
City of Haverhill, Massachusetts
City Hall, Room 100, 4 Summer Street, Haverhill, MA 01830
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