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REGISTERED SEX OFFENDER RISK LEVEL LOWERING APPLICATION

NAME: LAST______FIRST______MIDDLE______DATE OF BIRTH ______SOCIAL SECURITY NUMBER ______PHONE NUMBER ______

YOUR CURRENT OFFENDER RISK LEVEL: LEVEL II ______LEVEL III ______

DOC # ______Name of Previous DOC /CCO ______

CURRENT ADDRESS______CITY______STATE______ZIP______

HOW LONG AT CURRENT ADDRESS ______

PREVIOUS ADDRESS______CITY ______STATE______ZIP______

HOW LONG AT ADDRESS______

MARITAL STATUS______SPOUSE’S NAME______

CHILDREN: NAME(S) ______AGE ______

HAS IT BEEN 5 YEARS SINCE YOU WERE RELEASED FROM CONFINEMENT? YES ______NO ______

AS PART OF YOUR SENTENCE, WERE YOU REQUIRED TO PARTICIPATE IN A SEX OFFENDER TREATMENT PROGRAM? YES ______NO ______

HAVE YOU SUCCESSFULLY COMPLETED A SPECIALIZED “SEX OFFENDER SPECIFIC” TREATMENT PROGRAM? YES ______NO ______IF YOU SUCCESSFULLY COMPLETED A PROGRAM, YOU MUST PROVIDE THE TREATMENT PROVIDERS, NAME, ADDRESS & PHONE NUMBER, ALONG WITH A TREATMENT SUMMARY SIGNED BY THE TREATMENT PROVIDER. ______

HAVE YOU HAD AN EVALUATION WITHIN THE LAST 12 MONTHS WITH A CERTIFIED SEX OFFENDER SPECIFIC TREATMENT PROVIDER, WHICH INCLUDED A POLYGRAPH? YES ______NO ______

PROVIDE THE DATE OF COMPLETION, THE NAME, ADDRESS & PHONE NUMBER OF TREATMENT PROVIDER AND A COPY OF THE TREATMENT SUMMARY SIGNED BY TREATMENT PROVIDER. ______

HAVE YOU HAD ANY CRIMINAL ARRESTS OR CONVICTIONS SINCE THE ORIGINAL SEX OFFENSE? YES ______NO ______

IF YES, PLEASE LIST BELOW - (If necessary, you can include additional information on a separate sheet of paper.) ______

PRESENT EMPLOYER ______POSITION______ADDRESS______PHONE NO.______START DATE______

PREVIOUS EMPLOYER______POSITION______ADDRESS______PHONE NO______HOW LONG EMPLOYED BY PREVIOUS EMPLOYER______

LIST ANY JOB TRAINING AND / OR EDUCATION RECEIVED SINCE CONVICTION: ______

LIST NAMES AND PHONE NUMBERS OF AT LEAST 3 REFERENCES. ATTACH A COPY OF WRITTEN REFERENCES, INCLUDING REFERENCE FROM DOC/CCO. ______

PLEASE FILL IN BELOW THE REASON(S) YOU FEEL YOUR RISK LEVEL SHOULD BE LOWERED. ______