SEXUAL OFFENDER/SEXUAL PREDATOR !LEASE PRINT OR TYPE ... Complete all sections. 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% 2.4Floor. St. Thann,V1 00602 SECTION A — Type/Status 14 SECTION B • Contributing Agency Information -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 Fist 1 (fi-G, ( C Alias: SSN#:0/1 0%-14/1÷33Y /Alien If: /hit* DOB: [ -C mom ISi POB: PG/ '1.), - VI Driver's License#: 0 0 0 0 c3 21-Q 3 ki Exp. Date: /- 2-0 if -- i v 0 Race: “-, Sex: N HI: WA' Are You to WI Hair: r Ot o t ) Eyes: V Scars, Marks, Tattoos: 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 tMailing Address: Name: Stz:,It. r-I-Cs. Relationship: 1 -tle; 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#: Date SECTION G - Offense Information VICTIM w Adult [ ] Minor I J Acquitted by Reason of Insanity —) 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. Justice. Within five In (5) the working event you day are of moving being placed under any type of supervision in the community you must use this form to register with (he V.I. Department of (5) days of first residing to or returning to the USVI from another jurisdiction, you must register with the V.I. Department of Justice within five in or returning to the USVI. 2. In the the V.I. event Department there is of a Justice change within in your permanent or temporary residence after initial registration and any subsequent changes thereafter, you must notify three (3) days after arrival at your new residence. 3. In departure the event and there also is register a change in your address outside the USVI, you must register your new address with the V.1. Department of Justice prior to requirement. In your new jurisdiction within len (10) days after establishing residence there if the new jurisdiction has a registration 4. You to be are a sexually required violent to verify predator, your address with the V.I. Department of Justice annually on the anniversary of your initial registration. II you were determined release or commencement of parole. you must verify your address with the V.1. Department of Justice every ninety (90) days after the dale of your initial 5. more Failure than to comply two (2) with years, the or above both. requirements shall subject you to a fine of not less than $3,000.00 or imprisonment for nol less than three (3) months or Registration Be Reminded and that Notification even if you Act may not be required to register under Virgin Islands Law, under Title I of the Adam Walsh Act entitled the 'Sexual Offender jurisdiction where he or she 1SORNA), all intividuals convicted of a sex offense are required to register and keep their registration current in each resides, is an employee and is a student. FAILURE TO DO SO MAY SUBJECT YOU TO CRIMINAL PROSECUTION Registrant: I acknowledge that the above requirements as set forth have been explai tome. / . 9( I II t Witness: I certify abo that I specifically informed nd he indicate me an the o rider of his /her duties as have set forth mole 1 ndirg se duties. 6 a S e Regi li 0 I p 3 (O/A lum of R I nel r • 1 7e( it Print N Data Printratmli Dale EFTA00304441