Sex Offender Registration Form

Username: *

NLU ID #: *

Select your status: * Child Sex Offender (victim under 18) Sex Offender (victim over 18) Adjudicated Juvenile Delinquent Sex Offender

Select the option that best describes the time you are entering this form: * Student Initial Enrollment Student Renewal Student End of Enrollment Employee Initial Employment Employee Renewal Employee Change in Employment Employee End of Employment Other

Full Name: *

Date of Birth: *

Address: *

Phone Number: *

Email Address: *

LEADS Number: *

Date of Beginning of Enrollment/Employment: *

Date of End of Enrollment/Employment: *

Select the option that best describes the time you are entering this form: * Chicago Elgin Lisle North Shore Wheeling Miilwaukee Tampa

Duty to Register:

Write your name below to acknowledge that you have read and understand each item

► Completion of this form does not constitute an annual or quarterly registration. You must register, in person, with the law enforcement agency of jurisdiction in which you reside.

► Completion of this form does not constitute an annual or quarterly registration. You must register, in person, with the law enforcement agency of jurisdiction in which you reside.

► You must, within 3 days of beginning enrollment/employment at NLU, notify in person the agency of jurisdiction in which you reside, the agency of jurisdiction in which you are employed by NLU, and the Student Conduct Officer/Office of Human Resources through submission of this form.

► You must, within 3 days of changing your enrollment/employment status at NLU (commencement, termination, etc.), notify in person the agency of jurisdiction in which you reside, the agency of jurisdiction in which you are registered at/employed by NLU, and the Student Conduct Officer/Office of Human Resources through submission of this form.

► An out-of-state student/out-of-state employee residing in another state but registered at/employed by NLU must, within 3 days of registration/beginning employment at NLU, register with the agency of jurisdiction in which you are registered at/employed by NLU and the Student Conduct Officer/Office of Human Resources through submission of this form.

► You must renew your student/employee registration in person with the law enforcement agency having jurisdiction of your residence, in person with the law enforcement agency having jurisdiction over NLU, and with the Student Conduct Officer/Office of Human Resources through submission of this form within one year from the date of your most recent registration until you complete your registration requirement.

Signature: *