Check YES to all that applyCheck NO to all that DO NOT applyCrimeSelfOther household memberDate of conviction, guilty plea, no contest plea or pending chargesSentence
YES☐NO☐18 Pa.C.S. § 2709.1 (relating to stalking)
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YES☐NO☐18 Pa.C.S. § 2718 (relating to strangulation)
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YES☐NO☐18 Pa.C.S. § 2901 (relating to kidnapping)
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YES☐NO☐18 Pa.C.S. § 2902 (relating to unlawful restraint)
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YES☐NO☐18 Pa.C.S. § 2903 (relating to false imprisonment)
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YES☐NO☐18 Pa.C.S. § 2904 (relating to interference with custody of children)
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NO
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YES☐NO☐18 Pa.C.S. § 2910 (relating to luring a child into a motor vehicle or structure)
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NO
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YES☐NO☐18 Pa.C.S. § 3121 (relating to rape)
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YES☐NO☐18 Pa.C.S. § 3122.1 (relating to statutory sexual assault)
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NO
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YES☐NO☐18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse)
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NO
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YES☐NO☐18 Pa.C.S. § 3124.1 (relating to sexual assault)
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YES☐NO☐18 Pa.C.S. § 3125 (relating to aggravated indecent assault)
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NO
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YES☐NO☐18 Pa.C.S. § 3126 (relating to indecent assault)
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YES☐NO☐18 Pa.C.S. § 3127 (relating to indecent exposure)
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YES☐NO☐18 Pa.C.S. § 3129 (relating to sexual intercourse with animal)
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NO
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YES☐NO☐18 Pa.C.S. § 3130 (relating to conduct relating to sex offenders)
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NO
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Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2709.1 (relating to stalking)
Sentence_18 Pa.C.S. § 2709.1 (relating to stalking)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2718 (relating to strangulation)
Sentence_18 Pa.C.S. § 2718 (relating to strangulation)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2901 (relating to kidnapping)
Sentence_18 Pa.C.S. § 2901 (relating to kidnapping)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2902 (relating to unlawful restraint)
Sentence_18 Pa.C.S. § 2902 (relating to unlawful restraint)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2903 (relating to false imprisonment)
Sentence_18 Pa.C.S. § 2903 (relating to false imprisonment)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2904 (relating to interference with custody of children)
Sentence_18 Pa.C.S. § 2904 (relating to interference with custody of children)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2910 (relating to luring a child into a motor vehicle or structure)
Sentence_18 Pa.C.S. § 2910 (relating to luring a child into a motor vehicle or structure)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3121 (relating to rape)
Sentence_18 Pa.C.S. § 3121 (relating to rape)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3122.1 (relating to statutory sexual assault)
Sentence_18 Pa.C.S. § 3122.1 (relating to statutory sexual assault)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse)
Sentence_18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3124.1 (relating to sexual assault)
Sentence_18 Pa.C.S. § 3124.1 (relating to sexual assault)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3125 (relating to aggravated indecent assault)
Sentence_18 Pa.C.S. § 3125 (relating to aggravated indecent assault)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3126 (relating to indecent assault)
Sentence_18 Pa.C.S. § 3126 (relating to indecent assault)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3127 (relating to indecent exposure)
Sentence_18 Pa.C.S. § 3127 (relating to indecent exposure)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3129 (relating to sexual intercourse with animal)
Sentence_18 Pa.C.S. § 3129 (relating to sexual intercourse with animal)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3130 (relating to conduct relating to sex offenders)
Sentence_18 Pa.C.S. § 3130 (relating to conduct relating to sex offenders)