First Name: required

Middle Name:

Last Name: required

Alias(es)/Maiden Name:

Date of Birth (MM/DD/YYYY): required

Information provided on this form is confidential, and protected by attorney-client privilege. This information will not be shared without your consent.

How would you prefer that our office contact you? required
MailEmailPhone

Do you authorize release of your information to the California Department of Justice for us to obtain a copy of your criminal history? required
YesNo

Mailing Address:

Address Line 1: required

Address Line 2:

City: required

State:
---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code: required

Phone Number:

Email:

SSN: required

Driver's License:

CII (SID):

You must include your CII # on the application. CII is located on your Proof of Registration and your Tier Notification Letter — see below.

* * *

ALTERNATE CONTACT PERSON

Optional. This will help us locate you in the future regarding post-conviction relief.

First and Last Name:

Relationship to You:

Address Line 1:

Address Line 2:

City:

State:
---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code:

Phone Number:

Email:

* * *

CURRENT PROOF OF REGISTRATION

We must have proof of your current registration to petition for removal from registry.

Are you currently registered? required
YesNo

County (include state if not CA):

Agency:

Do you have your proof of registration? required
YesNo

Date of Registration (MM/DD/YYYY):

* * *

TIER NOTIFICATION LETTER (TNL)

This is a letter that you receive from your registering agency telling you which tier you are in. You should request your TNL from your agency ASAP.

Have you obtained your Tier Notification Letter? required
YesNo

DOJ Designated Tier: required
---Tier 1 - AdultTier 2 - AdultTier 3 - AdultTier 1 - JuvenileTier 2 - JuvenileUnknown

Please attach copies of your proof of registration and/or TNL below, or provide them as soon as possible.
Accepted file types: docx, jpg, jpeg, pdf, png. Maximum file size: 3 MB.

Other ways to submit your documents:
Email: Reply to the confirmation email you receive and attach the document(s).
Mail: Post-Conviction Unit Office, 900 E. Gilbert St., Bldg. 7, San Bernardino, CA 92415
In person: Any San Bernardino Public Defender Office (click here for locations)

* * *

MOST RECENT SEX CONVICTION

Complete as much information as possible.

PC§:

Crime:

County (include state if not CA):

Court Case Number:

Court:
AdultJuvenile

Arrest Date:

Conviction Date:

Sentence:

Release Date:

Total Sex Convictions:

Total Sex Cases:

Out of State (Fed/Military) Sex Offense?
YesNo

    Jurisdiction:

    Information:

Failure to Register Conviction(s)? required
YesNo

    Information:

* * *

Have you been in custody since release from sex case? required
YesNo

If you have been arrested, please provide information below:

Date:

Court Case No.:

Charge(s):

Sentence:

County:

* * *

HISTORY

Do any of the following apply to you?

Prior civil commitment? required
YesNo

    If yes, what type?
SVPMDSONGI for 290Other -- explain below

    Other:

Any open criminal case? required
YesNo

    If yes, charge:

    County:

Prior life sentence? required
YesNo

    Was life sentence for 667.61 or 667.71 one-strike sex crime?
YesNo

Currently in custody? required
YesNo

Currently on parole/probation/supervision? required
YesNo

    If in custody or on parole/probation/supervision:

    Court Case No.

    County:

    Booking/CDCR No.:

* * *

Additional information we may need to process your application: