THE APPROPRIATE REASON(S) BELOW: New Registration Verification Address Change Employment Change Other 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 TELEPHONE 11. TELEPHONE - - - - TELEPHONE? YES NO SECTION B - REGISTRATION INFORMATION SECTION C - PHYSICAL DESCRIPTION 14. DOES OFFENDER 15. HEIGHT 16. 17. HAIR COLOR 18. EYE COLOR WEAR GLASSES? WEIGHT YES NO Feet Inches Lbs. 19. RACE 20. ETHNICITY White Asian/Pacific Islander Unknown Hispanic Non-Hispanic Unknown Black American Indian/Alaskan Native 21. BIRTH STATE/TERRITORY 22. BIRTH COUNTRY SECTION D - IDENTIFIERS 23. HAVE PALM 24. HAS DNA BEEN 25. PASSPORT NUMBER 26. INMATE NUMBER PRINTS BEEN TAKEN? TAKEN? YES NO YES NO 27. IMMIGRATION (ALIEN) ID 28. IMMIGRATION STATUS 29. FBI NUMBER SECTION E - ALIASES 30. CURRENT ALIASES/NICKNAMES FIRST NAME LAST NAME If the alias 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 LOCATION DESCRIPTION DESCRIPTION 33. AMPUTATIONS 34. MARKS LOCATION DEFORMITIES MOLE SKIN DISCOLORATION UNKNOWN DESCRIPTION LOCATION DESCRIPTION DEFORMITIES MOLE SKIN DISCOLORATION UNKNOWN LOCATION DESCRIPTION SECTION G - ADDRESS INFORMATION CORRECTIONAL FACILITY
THE APPROPRIATE REASON(S) BELOW: New Registration Verification Address Change Employment Change Other 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 TELEPHONE? YES NO 10. MOBILE TELEPHONE - - 11. TELEPHONE - - SECTION B - REGISTRATION INFORMATION SECTION C - PHYSICAL DESCRIPTION 14. DOES OFFENDER WEAR GLASSES? YES NO 15. HEIGHT Feet Inches 16. WEIGHT Lbs. 17. HAIR COLOR 18. EYE COLOR 19. RACE White Asian/Pacific Islander Unknown Black 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 FIRST NAME LAST NAME If the alias 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
Sexual%20Offender%20Registration%20-%20SP%204-218%20(locked).docx