Sor Form 002r Sex Offender Registration Form (Page 2 of 2) in pdf

Instructions for Completing the Sex Offender Registration Form

USE: This form is to be used by the Sex Offender, Sex Offender Registry, and all agencies responsible for registering sexual offenders

who are unclassified or have been classified by the Sex Offender Registry Board as Level 1, Level 2, Level 3, or if determined to be a

Sexually Violent Predator. If necessary, use a separate piece of paper for additional information.

(Items 2, 3, 5, 6, & 7 in SECTION C below do not have to be completed by UNCLASSIFIED Offenders)

SECTION A: This section is used to record the SON & classification status. Check the appropriate box indicating the level the

offender has been classified. Note to Police: This is verified by the Database (DB).

SECTION B: This section is used to record the name and contact number of the agency responsible for completing and submitting the

registration form and identifying the person representing that agency who took the registration.

SECTION C: The section is used to record administrative, physical, and legal information about the registrant.

1. Name – The last, first and middle name of the registrant

2. SSN – The 9-digit social security number of the registrant, INS alien number, or passport number and country of issue

3. Other Name(s) Used - Legal name changes, nick names, or other names commonly used.

4. DOB – record the registrant’s date of birth numerically by month, day, and 4-digit year.

5. POB – record the registrant’s place of birth by city and state.

6. Demographics- race, sex, hair color, eye color, height, and weight

7. Scars/Marks/Tattoos – record any scars, marks, or tattoos (including piercings) on the registrant’s body.

8. Driver’s License or ID: record if different from the registrant’s SSN. Identify the state of issues if not MA.

9. Registered as a Sex Offender in another State – check the appropriate box. If yes, record the state and the risk level, if known.

Note to Police: The III will also have information related to the registrant as registered as a sex offender in other states.

SECTION D: This section is used to record all addresses where the offender may live or receive mail. Also provides a name and

address for their nearest relative. Use the reverse side of the form or additional pages to record additional addresses.

1. Current Residence Address – record the street number and name, apartment/lot/building number, city, county, state, and zip for

the location where the registrant lives. THIS CANNOT BE A POST OFFICE BOX.

2. Secondary or Out of State Address - record the street number and name, apartment/lot/building number, city, county, state, and

zip for the location where the registrant lives on a temporary basis, to include vacations. THIS CANNOT BE A POST OFFICE

BOX. Secondary address is defined as "the addresses of all places where a sex offender lives, abides, lodges, or resides for a

period of 14 or more days in the aggregate during any calendar year and which is not a sex offender's primary address; or a

place where a sex offender routinely lives, abides, lodges, or resides for a period of 4 or more consecutive or nonconsecutive

days in any month and which is not a sex offender's permanent address, including any out-of-state address."

3. Mailing Address – record the post office or other mailbox number, the street number and name, apartment/lot/building number,

city, county, state, and zip for the location where the registrant receives mail if other than his live address.

4. HOMELESS, the registrant must provide the city and approximate location within that city. Provide Shelter name & address, if

applicable. A mailing address is strongly suggested in the event SORB must communicate with the offender. Note to Police:

This is the address that will be coded as “LIVE” in the DB.

SECTION E: This section is used to record the identification of any vehicle, mobile home, trailer, manufactured home, vessel, or

houseboat owned or operated by the registrant. Use the reverse side of the form for additional items.

1. Closest Living Relative – Record the name, relationship, and address of the registrant’s closest living relative for notification in

case of emergency.

SECTION F: This section is used to record where the registrant works. Include the Employer name, address of employer, and

telephone number. Occupation – record what type of work the registrant normally does (i.e. landscaper, teacher, bus driver, framer, etc.)

SECTION G: This section is used to record where the registrant attends an Institution of Higher Learning. Include the name and

address of the school, and campus if a satellite or extension. Include the enrollment start and end dates.

SECTION H: This section is used to advise the registrant of his legal obligations to notify the SORB or the police department of any

changes in his registration status. The registrant must check that he understands his duties and sign the form. If registering at a law

enforcement office, the officer witnessing the individual sign the form should sign in the space provided.

* Acceptable forms of identification are: rent or mortgage receipt, utility bill, bank or credit card statement, passport, drivers'

license or official photo identification issued by the registry of motor vehicles.

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

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

SOR FORM 002R Revised 10/10

Sor Form 002r Sex Offender Registration Form Page 2

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