CHECK THE APPROPRIATE REASON(S) BELOW: ( ) New Registration ( ) Verification ( ) Address Change ( ) Employment Change ( ) SECTION A - OFFENDER INFORMATION 1. PA SID 2. SOCIAL SECURITY NUMBER 3. DATE OF BIRTH / / - - 4. FIRST NAME 5. MIDDLE NAME 6. LAST NAME 7. GENDER 8. SUFFIX MALE FEMALE UNKNOWN 9. DOES OFFENDER HAVE A MOBILE 10. MOBILE PHONE 11. PHONE PHONE? YES NO - - - - SECTION B - REGISTRATION INFORMATION SECTION C - PHYSICAL DESCRIPTION 14. DOES OFFENDER 15. HEIGHT 16. 17. HAIR 18. EYE COLOR WEAR GLASSES? WEIGHT YES NO Feet Inches Lbs. 19. RACE 20. ETHNICITY White Asian/Pacific Islander Unknown Hispanic Non-Hispanic Unknown American Indian/Alaskan Native 21. BIRTH STATE/TERRITORY 22. BIRTH COUNTRY SECTION D - IDENTIFIERS 23. HAVE PALM PRINTS 24. HAS DNA BEEN 25. PASSPORT NUMBER 26. INMATE NUMBER BEEN TAKEN? TAKEN? YES NO YES NO 27. IMMIGRATION (ALIEN) ID 28. IMMIGRATION STATUS 29. FBI NUMBER SECTION E - ALIASES 30. CURRENT ALIASES/NICKNAMES NAME LAST NAME If the is only one name, place an in the Name” field and write the alias in the Name” field. “X” “First “Last SECTION F - SCARS/MARKS/TATTOOS/MISSING BODY PARTS (AMPUTATIONS) 31. SCARS 32. TATTOOS LOCATION DESCRIPTION LOCATION DESCRIPTION 33. AMPUTATIONS 34. MARKS LOCATION DESCRIPTION DEFORMITIES MOLE SKIN DISCOLORATION UNKNOWN LOCATION DESCRIPTION ------------------------------------------------------------------------------------------------------ DEFORMITIES MOLE SKIN DISCOLORATION UNKNOWN LOCATION DESCRIPTION SECTION G - ADDRESS INFORMATION CORRECTIONAL FACILITY
CHECK THE APPROPRIATE REASON(S) BELOW: ( ) New Registration ( ) Verification ( ) Address Change ( ) Employment Change ( ) SECTION A - OFFENDER INFORMATION 1. PA SID 2. SOCIAL SECURITY NUMBER - - 3. DATE OF BIRTH / / 4. FIRST NAME 5. MIDDLE NAME 6. LAST NAME 7. GENDER MALE FEMALE UNKNOWN 8. SUFFIX 9. DOES OFFENDER HAVE A MOBILE PHONE? YES NO 10. MOBILE PHONE - - 11. PHONE - - SECTION B - REGISTRATION INFORMATION SECTION C - PHYSICAL DESCRIPTION 14. DOES OFFENDER WEAR GLASSES? YES NO 15. HEIGHT Feet Inches 16. WEIGHT Lbs. 17. HAIR 18. EYE COLOR 19. RACE White Asian/Pacific Islander Unknown American Indian/Alaskan Native 20. ETHNICITY Hispanic Non-Hispanic Unknown 21. BIRTH STATE/TERRITORY 22. BIRTH COUNTRY SECTION D - IDENTIFIERS 23. HAVE PALM PRINTS BEEN TAKEN? YES NO 24. HAS DNA BEEN TAKEN? YES NO 25. PASSPORT NUMBER 26. INMATE NUMBER 27. IMMIGRATION (ALIEN) ID 28. IMMIGRATION STATUS 29. FBI NUMBER SECTION E - ALIASES 30. CURRENT ALIASES/NICKNAMES NAME LAST NAME If the is only one name, place an “X” in the “First Name” field and write the alias in the “Last Name” field. SECTION F - SCARS/MARKS/TATTOOS/MISSING BODY PARTS (AMPUTATIONS) 31. SCARS LOCATION DESCRIPTION 32. TATTOOS LOCATION DESCRIPTION 33. AMPUTATIONS LOCATION DESCRIPTION 34. MARKS DEFORMITIES MOLE SKIN DISCOLORATION UNKNOWN LOCATION DESCRIPTION ------------------------------------------------------------------------------------------------------ DEFORMITIES MOLE SKIN DISCOLORATION UNKNOWN LOCATION DESCRIPTION SECTION G - ADDRESS INFORMATION CORRECTIONAL FACILITY
Sex%20Offender%20Registration%20SP%20218.docx