"1",1\ 1\I -\\D‘ Di PAR I Mi . \ i 1H II NIII I Ol i ! 7! 11 1()K \I) CIl \l t \I % 'Rol \ . -. \: ‘I t 'I I I \Di R RI (d.i bt‘, SEXUAL OFFENDER REGISTRATION FORM FOR USE BY LAW ENFORCEMENT AGENCIES PLEASE PRINT - COMPLETE ALL SECTIONS SECTION A- Tier/Status SECTION B SECTION B vi Tier ! [ ] Tier I, [ j Tier III [ ] New Registratior [ I Modify Data ()ft Rental Registratial [ : :aro* I 1 Praetor: [ I Supervised Release SECTION 0 - Registration Information .___.. SSW. Oir)- ...--„ C* I S V 1173 ti 1" Y id Alien #. /-1, -(V _ Name: C. VS11.<4` ....)- 4klisciAlias:_______ ar i ; no 14 • tkire . e DOB: I — t 3- VI P08: Drivers License#:r i „ VZ.:71 -e Exp wit 1120117 _ V)! Race:_t, Sex. rA.f_ Ht.. Wt:._ Litt, Hair: _el__ Eyes_. IL/ Scars. 700'. Marks. Tattoos: SECTION E- Residence I I HOMELESS Closest Living Relative I I NIA a eft Name. Aettoit Relationship rites , Physical Address: 1-.> '1"iewle.-, . Mailing Address: I Q0 144 [t.izi_ J 4 i PS 2 Temporary Addre Contact ft Home: Cellular: `It I ) ‘513 -14 Contact #: Home: 7 ss:-)r-y Iv Cellular Lt cen _I -)* SECTION F - Internet Identifiers -List any and all email addresses used. an social network identifiers Instant Messaging addresses [ ] N/A and identifiers. designations or monikers in intemet communications and postings, and SECT ION G -_Erriploy7ent it •rlinPloYed [ ) Unemployed co.) Contact Person._ . . . Or P. J'e't Occupation. Employer. _ Alfie: _Slaallio idol Telephone_ )j - 2J_ Z. r - Address: 12 _... ._ _gant‘se ___ Date Employment:.__ _ __ _ , __ Occupation _ _ .. Date Employment __ _ Employer: Contact Person.` __ ____ ____ Telephone Address. SECTION H - Volunteer Information _ _ . _ _ Contact Person._ .. . ______ ___ _ . Duties ____. Duties Organization . . _Jil_i_iki Telephone _. _ . Address. Organization _ . Contact Person.___ _ Telephone: Address: SECTION I - Occupational License Informa