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 w