HomeMy Public PortalAboutSORI WatertownCOMMONWEALTH OF MASSACHUSETTS
SEX OFFENDER REGISTRY BOARD
REQUEST FOR SEX OFFENDER REGISTRY INFORMATION
Please check appropriate box: I am a Recreation Employee:
I am a Recreation Contractor:
Name (PLEASE PRINT):
School/Location: Date of birth: Telephone No:
Address:
Personal identifying characteristics:
Gender: Race: Height: Weight: Eye Color: Hair Color:
Optional information (e.g. license plate number, parents' names, etc.):
Signature: Date:
**********WARNING
SEX OFFENDER REGISTRY INFORMATION SHALL NOT BE USED TO COMMIT A CRIME OR TO ENGAGE IN
ILLEGAL DISCRIMINATION OR HARASSMENT OF AN OFFENDER. ANY PERSON WHO USES INFORMATION
DISCLOSED PURSUANT TO M.G.L. C. 6, §§ 178C —178P FOR SUCH PURPOSES SHALL BE PUNISHED BY NOT
MORE THAN TWO AND ONE HALF (2''A) YEARS IN A HOUSE OF CORRECTION OR BY A FINE OF NOT MORE
THAN ONE THOUSAND DOLLARS ($1000.00) OR BOTH (M.G.L. C. 6, § 178N). IN ADDITION, ANY PERSON WHO
USES REGISTRY INFORMATION TO THREATEN TO COMMIT A CRIME MAY BE PUNISHED BY A FINE OF NOT
MORE THAN ONE HUNDRED DOLLARS ($100.00) OR BY IMPRISONMENT FOR NOT MORE THAN SIX (6)
MONTHS ( M.G.L. C. 275, § 4).
All requests for sex offender information must be made on this form and mailed to the Sex Offender Registry Board, Attn:
SORI Coordinator, P.O. Box 4547, Salem, MA 01970, along with a self-addressed stamped envelope.
1 hereby request that the following information be used to determine whether the identified individual is a sex
offender required to register in Massachusetts.
The Board will provide a report that includes the following information: whether the person identified is a sex
offender with an obligation to register, the offense(s) for which the offender was convicted or adjudicated, and
the date(s) of the conviction(s) or adjudication(s). Please be advised that the law only permits the public to
receive information on sex offenders required to register and finally classified by the Board as a level 2
(moderate risk) or level 3 (high risk) offender. Therefore, information is not available to the public if the
identified individual is a level 1 (low risk) offender or if he/she has not yet been finally classified by the Board.
All requests shall be recorded and kept confidential, except to assist or defend in a criminal prosecution.
Requestor's name:
Address:
Telephone number:
Gayle M. Shattuck, Personnel Director '
Town of Watertown 149 Main Street Watertown, MA 02472
617-972-6443
I swear under the pains and penalties of perjury that 1 am the above -named person, at least 18 years of age, and I
am requesting information for my own protection, the protection of a child under 18 years of age, or for the
protection of another person for whom 1 have responsibility, care or custody.
Requestor's signature:
9/11/13
Date: