EFTA00304441.pdf

SEXUAL OFFENDER/SEXUAL PREDATOR REGI !LEASE PRINT OR TYPE ... Complete all sections. STRATION FORM I attach finporpdat card. phiRograph, and smells markers then FOR USE BY LAW ENFORCEMENT AGENCIES available, and submit to IM Department of Justice. GERS &SIMI% 2.4 Floor. St. Thann,V100602 SECTION A — Type/Status SECTION B • Contributing Agency Information 14-Sex Offender Agency Name: - [ J Habitual Sexual Offender Agency Address: I 1 Sex Predator Phone Number: ( ) Fax: ( ) [ 1 New Registration Checked for Warrants: I 1 Local System [ J FCIC.NCIC SYSTEM [ 1 Modify Data CCH for Sex Offenses: [ J Yes [ 1No SECTION C • Registratiotnformation Name: erney 1 (fi-G, C Alias: Fist ( SSN#:01 / 0 %-14/1÷33Y /Alien If: /hit* DOB: [ -CI Si POB: PG/ '1.), - VI Driver's License#: 0 0 0 0 c3 21-Q 3 ki mom Exp. Date: /- 2-0 if -- 0 Race: “-, Sex: N HI: to i v WI Hair rOt o : Are You Registered as a Sex Offender in Another State: [ 1NO t ) Eyes: V Scars, Marks, Tattoos: WA' [ ] YES If YES, which state: and at what LEVEL SECTION D - Residence a_ i .)-- ‘ 0 .- Physical Address: 1-I IF t- Closest Living Relative Name: Stz:,It. r-I-Cs. Relationship: 1-tle; Mailing Address: to 0 u IZAI Boots Address: (, o f >4 4, Temporary Address: Contact #: Home . cmilltar Contact #: Home: Cellular SECTION E • Employment [ J Employed [ J Unemployed Employer: T C Contact Person: Telephone Occupation: V=71.4. •Address: r , Par /J k7 Date Employment h.- lit SECTION F: Vehicle, Trailer, Vessel, Etc. -.. Description (Year/Make/ModeVColor Scheme) : License Plate#: VIN#: 4- , A Ade) SECTION G - Offense Information VICTIM w Adult [ ] Minor I J Acquitted by Reason of Insanity Date of Conviction Offense Committed Place of Conviction Court/Court No. AG No. —) / Di Pil Inr-TI DN. . Fc• A IPA Y ,,, c,.: r- 01-ni-il,„; r c .. fi 0 (ic SECTION H • PLEASE READ CAREFULLY BEFORE SIGNING As a Sexual Offender or Sexual Predator (Title 14 V.I.C. § 1721.1731) you are required by law to abide by the following: I. Within five (5) working day of being placed under any type of supervis ion in the community you must use this form to register with (he Justice. In the event you are moving to or returning to the USVI from V.I. Department of another jurisdiction, you must register with the V.I. Department of Justice (5) days of first residing in or returning to the USVI. within five 2. In the event there is a change in your permanent or temporary residenc e after initial registration and any subsequent changes thereafter, the V.I. Department of Justice within three (3) days after arrival you must notify at your new residence. 3. In the event there is a change in your address outside the USVI, you must register your new address with the V.1. Department departure and also register In your new jurisdiction within len (10) of Justice prior to days after establishing residence there if the new jurisdiction has requirement. a registration 4. You are required to verify your address with the V.I. Department of Justice annually on the anniversary of your initial registration. II you to be a sexually violent predator, you must verify your address with were determined the V.1. Department of Justice every ninety (90) days after the dale release or commencement of parole. of your initial 5. Failure to comply with the above requirements shall subject you to a fin e of not less than $3,000.00 or imprisonment for nol less than three more than two (2) years, or both. (3) months or Be Reminded that even if you may not be required to register under Virgin Islands Law, under Title I of the Adam Walsh Act entitled the 'Sexual Registration and Notification Act 1SORNA), all intividuals convicted of Offender a sex offense are required to register and keep their registration jurisdiction where he or she resides, is an employee and is a student. current in each FAILURE TO DO SO MAY SUBJECT YOU TO CRIM INAL PROSECUTION Registrant: Witness: I acknowledge that the above requirements as set forth have been I certify that I specifically informed the o rider of his /her duties explai tome. as have set forth / . abo nd he indicate me an mole 1 ndirg se duties. 9(I II t 6a lum of R Printratmli I nel r • 1 7e( it Dale S Print N e Regi li I p 0 3 (O/A Data EFTA00304441