Sor Form 002r Sex Offender Registration Form printable pdf download

SEX OFFENDER REGISTRATION FORM

PD INSTRUCTIONS –

Have registrant complete the

form & sign. Attach photograph and fingerprint card.

Unclassified & Level 1…Mail to: SORB PO Box 4547, Salem MA 01970

Submit to: SORB PO Box 4547, Salem, MA, 01970.

Level 2 & Level 3…Register at Police Department in City/Town of Residence

SECTION A – Type/Status

SECTION B – Contributing Police Department/Agency Information

Unclassified (Mail to SORB)

Level 1 (Mail to SORB)

PD or Agency Name:

Level 2 (At PD)

Level 3 (At PD)

Reporting Officer/Person:

Tel#_______________________

SON:

SVP (At PD)

SECTION C – Registrant Information (Please print legibly or type)

Name: ____________________________, ________________________________________ SSN: ___________-_______-_____________ Alien #______________

LAST

FIRST

MIDDLE

Other Name(s) Used:_____________________________________

DOB: ________/________/______________ POB: _________________________, _______

Month

Day

Year

CITY

STATE

Race: ____________ Sex: __________ Hair Color: _______________ Eye Color: ______________ Height ______’_______” Weight: __________lbs

Scars/Marks/Tattoos: _______________________________________________

Driver’s License or ID#: _____________________________________

Are You Registered as a Sex Offender in Another State:

YES

If YES, which state: ______________________ and at what LEVEL ___________

SECTION D Current Residence Address

Secondary OR Out of State Address (If different than Residence)

(Confirmed with 2 forms of verification*)

Street Address ___________________________________________________

NOTE: PO Box is not acceptable

Number/Street/Apt, Bldg, Lot, Etc

________________________________/________________________________

City/Town

County

City/Town

County

_________/_______________/_______________________________________

State

ZIP

Home Phone

State

ZIP

Home Phone

Mailing Address:

Homeless (Must register every 30 days)

(If different from residence, temporary address, or homeless location)

Location and/or Address ____________________________________________

Address _________________________________________________________

NOTE: PO Box is not acceptable

Number/Street/Apt, Bldg, Lot, Etc

Post Office Box or Number/Street/Apt, Bldg, Lot, Etc

________________________________/________________________________

City/Town

County

City/Town

County

_________/_______________/_______________________________________

Shelter Name (If applicable) ________________________________________

State

ZIP

Home Phone

SECTION E – Vehicle, Mobile Home, Trailer, Manufactured Home, Vessel

Closest Living Relative

Description (Year/make/model/color scheme): __________________________

Name: ___________________________ Relationship: __________________

Address _________________________________________________________

__________________________________________________________________

Number/Street/Apt, Bldg, Lot, Etc

License Plate #: _____________________ State: ______________

________________________________/________________________________

City/Town

County

Expiration Year: _____________ VIN#:_________________________________

_________/_______________/_______________________________________

State

ZIP

Home Phone

SECTION F – Employment :

Employed

Self-Employed

Unemployed

Volunteer

Employer: ________________________________________ Occupation: ___________________________ Telephone Number: ____________________________

Address _____________________

_______________________/________

________________________/_______________

______________/___ __

_ _/___________

Number/Street/Apt, Bldg, Lot, Etc

City/Town

County

State

ZIP

Employer: ________________________________________ Occupation: ___________________________ Telephone Number: ____________________________

Address _____________________

_______________________/________

________________________/_______________

______________/___ __

_ _/_______

____

Number/Street/Apt, Bldg, Lot, Etc

City/Town

County

State

ZIP

SECTION G – Institution of Higher Learning

Start Date ____________________ Ending Date ________________________

Name: ____________________________________________________Campus: ___________________________________________

Address _____________________________

_______________/________

________________________/_________________

____________/__ __

__ _/___________

Post Office Box or Number/Street/Apt, Bldg, Lot, Etc

City/Town

County

State

ZIP

You are advised that you must notify, in writing, the Sex Offender Registry Board and/or the Police

SECTION H - Please Read Carefully Before Signing –

Department in the city or town in which you reside not less than 10 days prior to any change in residence, employment, or attendance at an institution of

higher learning. You are further advised that you are required to immediately contact and advise of your presence, the appropriate authorities in any other

state in which you locate yourself for the purpose of residence, employment, or attendance at an institution of higher learning.

Failing to do so may subject you to criminal prosecution.

I have read and understand the above requirements, OR

the requirements were read to me and I understand these requirements. I do hereby attest that

the information I have provided is true and accurate. Signed, this

day of

under the pains and penalties of

_____________

________________________, _______,

perjury

DAY

MONTH