SEXUAL OFFENDER/SEXUAL PREDATOR REGISTRATION FORM

SEXUAL OFFENDER/SEXUAL PREDATOR REGISTRATION FORM PLEASE PRINT OR TYPE FOR USE BY LAW ENFORCEMENT AGENCIES Complete all sections, attach fingerprint Card, photograph, and genetic markers when available, and submit to the Department of Justice, GERS Building, 2°4 Floor, Virgin Islands. 00802 SECTION A — Status SECTION B - Contributing Agency Information et Sex Offender [ J Habitual Sexual Offender Agency Name. ( I Sex Predator Agency Address: (Court Order Required) Phone Number: ( ) Fax: ( ) [ I New Registration Checked for Warrants: I I Local System ( I FCIC.NCIC SYSTEM [ I Modify Data CCH for Sex Offenses: [ j Yes ( SECTION C - Registration Information Name: gpjFe eirtif(et), WT:L1C Hair fit..', Eyes: Blir VI Driver's Licensee 1#/r o, d 0 00C:4..17W SECTION D — Legal Residence Physical Address: L. 4• rinse. Mailing Address: • De, Telephone: Horn Work: Future Residence “issa Middle Exp. Date: r—Zia 'Ler SSNH Race grosi4. Ea• DOB: —L4 ri Age: ri M/D/Y C./ SEE:.} fir: 4' Scars. Marks, Tattoos: SECTION E - Employment Employer: FTC Date of Employment 1 —12- Current Temporary Residence: Closest Relative: tan Pero• Aia" 91.fre• Address: ia Relationship: Ba..roMet Telephone: thii4 Employed ( ) Unemployed Contact Person: 'Davao. Snalylct. Address: J.I,Ay SECTION F — Offense Information VICTIM Datesfreon,*_tign SECTION C Offense Committed Pro( 4;441 ( 'Adult b4 Minor place of Conviction pc.44-9'1A, Telephone [ j Acquitted by Reason of Insanity Court/Court No. AG ?LEASE READ CAREFULLY BEFORE SIGNING Ma Sexual Offender or Sexual Predator (Title 14 V1.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 supervision in the community you must use this form to register with the VA. Dtpaitment of Justice. In the event you are moving to or returning to the USVI from another jurisdiction, you must register with the Y.I. Department of Justice within five (S)days of fast residing in or returning to the USV1. • 2. In the event there is &change in your permanent or temporary residence after initial registration and any subsequent changes the:coda, you must notify the V.I. Department of Justice within three (3) days after arrival at your new residence. 3. In the event that is a change in your address outside the USVI, you must register your new address with the V.I. Department of Justice prior to departure and also register In your new jurisdiction within ten (I0) days after establishing residence there if the new jurisdiction has a legislation requirement. 4. You are required to verily your address with the V.I. Department of Justice annually on the anniversary of your initial registration. If you were determined to be a sexually violent predator, you must emit , your address with the V I. Department of Justice every ninety (90) days after the date of your initial release or commencement of patok. 5: Failure to comply with the above requirements shall subject you to a fine of not less than $3,000.00 or imprisonment for not less than three (3) months or more than two (2) roils, or both. Be Reminded that even if you may not be required to register under Virgin Islands Law, under Tide I of the Adam Walsh Act entitled the "Sexual Offender Registration and Notification Act "(SOMA), all individuals convicted of a sex offense are required to register and keep their registration current in each jurisdiction where lie or she resides, is an employee and Is o student Registrant: l acknowledge that the above requirements as set forth been ai to me. Signaye Print /Li 61 Witness: I certify jhat set fo dutie d the offender of hislbcr duties as have to me an under EFTA00309984