Form Sp 4-218 - Sexual Offender Registration Page 3
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1259. Responsible Agency Having Jurisdiction: Enter the responsible agency having jurisdiction in this residence
area.
60. Transient/Temporary: If applicable, place an “X” in the appropriate box.
Secondary Residence
61. Description: Enter a description of the secondary residence of the sexual offender (e.g., house, apartment,
cabin, shelter).
62. Telephone Number: Enter the telephone number of the secondary residence, including the area code.
63. Street Address 1: Enter the street address of the secondary residence.
64. Street Address 2:
Enter additional street address information of the secondary residence (include
apartment/room no.).
65. City: Enter the city of the secondary residence.
66. State: Enter the state of the secondary residence.
67. Zip Code: Enter the zip code of the secondary residence.
68. County: Enter the county of the secondary residence.
69. Country: Enter the country of the secondary residence.
70. Municipality: Enter the city/township/borough of the secondary residence.
71. Responsible Agency Having Jurisdiction: Enter the responsible agency having jurisdiction in this residence
area.
72. Transient/Temporary: If applicable, place an “X” in the appropriate box.
Mailing Address
73. Is Mailing Address the Same as Physical Address?: Place an “X” in the appropriate box. If NO is selected,
enter numbers 74-79.
74. Street Address 1: Enter the street address of the mailing address.
75. Street Address 2: Enter additional street address information of the mailing address (include apartment/room
no.).
76. City: Enter the city of the mailing address.
77. State: Enter the state of the mailing address.
78. Zip Code: Enter the zip code of the mailing address.
79. County: Enter the county of the mailing address.
SECTION H – SCHOOL INFORMATION
This section is used to record the sexual offender’s school information. (Complete only if enrolled as a student.)
80. Name of School: Enter the name of school the sexual offender attends.
81. Additional Information: Enter any additional information on the school.
82. Telephone Number: Enter the telephone number of the school, including the area code.
83. Street Address 1: Enter the street address of the school.
84. Street Address 2: Enter additional street address information of the school (include room no.).
85. City: Enter the city of the school.
86. State: Enter the state of the school.
87. Zip Code: Enter the zip code of the school.
88. County: Enter the county of the school.
89. Municipality: Enter the city/township/borough of the school.
90. Country: Enter the country of the school.
91. Start Date: Enter the enrollment date (numerically by month, day, and 4-digit year).
92. End Date: If known, enter the date the sexual offender will no longer attend school (numerically by month, day,
and 4-digit year).
93. Responsible Agency Having Jurisdiction: Enter the responsible agency having jurisdiction in the school area.
SECTION I – EMPLOYMENT INFORMATION
This section is used to record the sexual offender’s employment information.
Employer 1
94. Employer: Enter the name of the place of employment of the sexual offender.
95. Occupation: Enter the type of work performed (e.g., landscaper, teacher, framer).
96. Supervisor’s Name: Enter the name of the supervisor.
97. Telephone Number: Enter the telephone number of Employer 1, including the area code.
98. Street Address 1: Enter the street address of Employer 1.
99. Street Address 2: Enter additional street address information of Employer 1.
100. City: Enter the city of Employer 1.
101. State: Enter the state of Employer 1.
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