Form Sp 4-218 - Sexual Offender Registration Page 10

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SECTION K - INTERNET IDENTIFIERS
158. EMAIL ADDRESS
159. SITE IDENTIFIERS
SITE AFFILIATION(S)
List ALL email addresses affiliated with offender.
List ALL identifiers affiliated with offender (e.g., Facebook, Twitter, Tagged, Myspace).
SECTION L - LICENSE INFORMATION
DRIVER’S LICENSE
160. DRIVER’S LICENSE NUMBER
161. ISSUING STATE
162. EXPIRATION DATE
163. IS LICENSE CURRENT?
YES
NO
/
/
PROFESSIONAL LICENSE
164. LICENSE NUMBER
165. LICENSE TYPE
166. ISSUING AGENCY
167. ISSUING STATE
168. EXPIRATION DATE
169. IS LICENSE CURRENT?
/
/
YES
NO
SECTION M - OFFENSE
170. COUNTRY OF CONVICTION
171. STATE OF CONVICTION
172. COUNTY OF CONVICTION
173. OTN
174. OFFENSE
175. OFFENSE DATE
176. ARREST DATE
177. CONVICTION DATE
/
/
/
/
/
/
178. WAS OFFENDER ADJUDICATED DELINQUENT AS A JUVENILE?
179. WAS THE JUVENILE OFFENDER CIVILLY COMMITTED AS
YES
NO
A SEXUALLY VIOLENT DELINQUENT CHILD (SVDC)?
YES
NO
180. ADDITIONAL INFORMATION
181. WERE ANY OF THE OFFENDER’S
VICTIMS MINORS?
YES
NO
182. Victim 1
183. Victim 2
Age
Age
Victim 1 Gender
MALE
FEMALE
UNKNOWN
Victim 2 Gender
MALE
FEMALE
UNKNOWN
Victim 1 Relationship
Victim 2 Relationship
SECTION N - SUPERVISION
184. IS OFFENDER UNDER SUPERVISION?
185. SUPERVISING AGENCY
YES
NO
186. SUPERVISION START DATE
187. SUPERVISION END DATE
188. PAROLE NUMBER
/
/
/
/
ADDITIONAL COMMENTS:
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