Form Sp 4-218 - Sexual Offender Registration Page 8
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1238. STREET ADDRESS 1
39. STREET ADDRESS 2
40. CITY
41. STATE
42. ZIP CODE
43. COUNTY
44. MUNICIPALITY (City/Township/Borough)
45. COUNTRY
46. START DATE
47. END DATE
48. RESPONSIBLE AGENCY HAVING JURISDICTION
/
/
/
/
RESIDENCE(S) ADDRESS(ES) – PHYSICAL LOCATION OF OFFENDER
PRIMARY RESIDENCE
49. DESCRIPTION
50. TELEPHONE NUMBER
-
-
51. STREET ADDRESS 1
52. STREET ADDRESS 2 (Include Apartment/Room No.)
53. CITY
54. STATE
55. ZIP CODE
56. COUNTY
57. MUNICIPALITY (City/Township/Borough)
58. COUNTRY
59. RESPONSIBLE AGENCY HAVING JURISDICTION
60. TRANSIENT
TEMPORARY
SECONDARY RESIDENCE
61. DESCRIPTION
62. TELEPHONE NUMBER
-
-
63. STREET ADDRESS 1
64. STREET ADDRESS 2 (Include Apartment/Room No.)
65. CITY
66. STATE
67. ZIP CODE
68. COUNTY
69. MUNICIPALITY (City/Township/Borough)
70. COUNTRY
71. RESPONSIBLE AGENCY HAVING JURISDICTION
72. TRANSIENT
TEMPORARY
MAILING ADDRESS
73. IS THE MAILING ADDRESS THE SAME AS THE PHYSICAL ADDRESS?
YES
NO
(IF NO, COMPLETE THE MAILING ADDRESS INFORMATION BELOW)
74. STREET ADDRESS 1
75. STREET ADDRESS 2 (Include Apartment/Room No.)
76. CITY
77. STATE
78. ZIP CODE
79. COUNTY
SECTION H - SCHOOL INFORMATION (Complete only if enrolled as a student.)
80. NAME OF SCHOOL
81. ADDITIONAL INFORMATION
82. TELEPHONE NUMBER
83. STREET ADDRESS 1
84. STREET ADDRESS 2 (Include Room No.)
-
-
85. CITY
86. STATE
87. ZIP CODE
88. COUNTY
89. MUNICIPALITY (City/Township/Borough)
90. COUNTRY
91. START DATE
92. END DATE
93. RESPONSIBLE AGENCY HAVING JURISDICTION
/
/
/
/
SECTION I - EMPLOYMENT INFORMATION
EMPLOYER 1
94. EMPLOYER
96. SUPERVISOR’S NAME
95. OCCUPATION
97. TELEPHONE NUMBER
-
-
98. STREET ADDRESS 1
99. STREET ADDRESS 2
100. CITY
101. STATE
102. ZIP CODE
103. COUNTY
Page 8 of 12
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