Form Sp 4-218 - Sexual Offender Registration Page 7

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CHECK 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 PHONE
11. OTHER PHONE
PHONE?
YES
NO
-
-
-
-
SECTION B - REGISTRATION INFORMATION
12. OFFENDER STATUS
13. OFFENDER TYPE
Active
Inactive - Deported
Tier I
Sexually Violent Predator
Tier Pending
Active - Incarcerated
Inactive - Moved
Tier II
Sexually Violent Delinquent Child
Active - Transient
Tier III
Juvenile Offender
If Offender Type is unknown, place an “X” in “Tier Pending.”
SECTION C - PHYSICAL DESCRIPTION
14. DOES OFFENDER
15. HEIGHT
16. WEIGHT
17. HAIR COLOR
18. EYE COLOR
WEAR GLASSES?
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 PRINTS
24. HAS DNA BEEN
25. PASSPORT NUMBER
26. INMATE NUMBER
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 “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
32. TATTOOS
LOCATION
DESCRIPTION
LOCATION
DESCRIPTION
33. AMPUTATIONS
34. MARKS
DEFORMITIES
MOLE
SKIN DISCOLORATION
UNKNOWN
LOCATION
DESCRIPTION
LOCATION
DESCRIPTION
------------------------------------------------------------------------------------------------------
DEFORMITIES
MOLE
SKIN DISCOLORATION
UNKNOWN
LOCATION
DESCRIPTION
SECTION G - ADDRESS INFORMATION
CORRECTIONAL FACILITY
35. NAME OF FACILITY
36. DESCRIPTION
37. TELEPHONE NUMBER
-
-
Page 7 of 12

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