!LEASE PRINT OR TYPE ... Complete all sections. SEXUAL OFFENDER/SEXUAL PREDATOR REGISTRATION FORM I FOR USE BY LAW ENFORCEMENT AGENCIES attach finporpdat card. phiRograph, and smells markers then available, and submit to IM Department of Justice. GERS &SIMI% 2.4 Floor. St. Thann,V1 00602 SECTION A — Type/Status SECTION B • Contributing Agency Information 14-Sex Offender - [ J Habitual Sexual Offender I 1 Sex Predator [ 1 New Registration [ 1 Modify Data Agency Name: Agency Address: Phone Number: ( ) Fax: ( ) Checked for Warrants: I 1 Local System [ J FCIC.NCIC SYSTEM CCH for Sex Offenses: [ J Yes [ 1No SECTION C • Registratiotnformation Name: erney 1 (fi-G, C Alias: SSN#:0/1 0%-1/41÷33Y /Alien If: Fist ( /hit* DOB: [ -CI Si POB: PG/ '1.), - VI Driver's License#: 0 0 0 0 c3 21-Q 3 ki Exp. Date: /- 2-0 if -- mom i v 0 WA' Race: “-, Sex: N HI: to WI r o Hair: Ot t ) Eyes: V Scars, Marks, Tattoos: Are You Registered as a Sex Offender in Another State: [ 1 NO [ ] YES If YES, which state: and at what LEVEL SECTION D - Residence a_ i Closest Living Relative .)-- ‘ 0.- Physical Address: 1-I IF t- 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: Occupation: V=71.4. Telephone •Address: r , Par /J k7 Date Employment h.- lit -.. SECTION F: Vehicle, Trailer, Vessel, Etc. Description (Year/Make/ModeVColor Scheme) : 4- , A Ade) License Plate#: VIN#: 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