Victim Services Program Enrollment Request
SECTION A: OFFENDER INFORMATION
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Name of Offender
DOC Number
County of Conviction
County Cause Number, if Known
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Offense (Group A)
Aggravated Murder 1
Any violation of RCW 69.50.406
Arson 1
Assault 1
Assault of a Child 1
Bail Jumping (with Murder 1 offense)
Burglary 1
Child Molestation 1
Child Molestation 2
Child Molestation 3
Communication with a Minor for Immoral Purposes
Custodial Sexual Misconduct 1
Damaging Building etc., by explosion w/threats to human being (if prior to 7-27-97)
Dealing in Depictions of Minors engaged in Sexually Explicit Conduct
Explosive Devices Prohibited (possession of explosive device for unlawful purpose)
Homicide by Abuse
Homicide by Watercraft by being under the influence of intoxicating liquor or drugs
Homicide by Watercraft by disregard for the safety of others
Homicide by Watercraft by the operation by any vessel in a reckless manner
Incest 1
Incest 2
Indecent Liberties (with forcible compulsion)
Indecent Liberties (without forcible compulsion)
Kidnapping 1
Leading Organized Crime
Malicious Explosion 1
Malicious Explosion 2
Malicious Placement of Explosives 1
Manslaughter 1
Murder 1
Murder 2
Patronizing a Juvenile Prostitute (if after 7-1-01)
Rape 1
Rape 2
Rape 3
Rape of a Child 1
Rape of a Child 2
Rape of a Child 3
Robbery 1
Sending, Bringing into State, Depictions of Minor engaged in Sexually Explicit Conduct
Sexual Exploitation of a Minor
Sexual Misconduct with a Minor 1
Sexually Violent Predator escape
Sexually Violating Human Remains
Statutory Rape 1
Statutory Rape 2
Statutory Rape 3
Trafficking 1
Trafficking 2
Treason
Use of a Machine Gun in the commission of a Felony
Vehicular Homicide
Voyeurism
None of the Above
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Offense (Group B) **
Arson 2
Assault 2
Assault of a Child 2
Create, Deliver, or Possess a Counterfeit Controlled Substance
Cyberstalking (if after 7-1-04)
Drive by Shooting
Extortion 1
Failure to Register as a Sex Offender
Harassment (Felony)
Kidnapping 2
Malicious Harassment
Manslaughter 2
Manufacture, Deliver, or Posses with intent to Manufacture or Deliver a Controlled Substance
Robbery 2
Stalking
Telephone Harassment
Threats against Governor or Family
Vehicular Assault while under the influence of intoxicating liquor or any drug
Vehicular Assault by the operation or driving of a vehicle in a reckless manner
None of the Above
**Unless there is sexual motivation, the crime is NOT eligible if offender is convicted of:
-ATTEMPT to commit a Group B crime
-CRIMINAL SOLICITATION of a Group B Crime
-CONSPIRACY to commit a Group B Crime
Offense
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Offender Prosecuted as
Adult
Juvenile
SECTION B: PROGRAM ENROLLEE INFORMATION
Your Name as Program Enrollee
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First Name
MI
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Last Name
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Street of Mailing Address
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City
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State
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ZIP
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Telephone Number
Message Telephone
Mr.
Mrs.
Ms.
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Relationship (Check one)
Victim
Witness
Next of Kin to Victim
Parent of Minor
Guardian of Minor
Other
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Date of Birth
Check if New Address
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REQUIRED:
By checking this box, I hereby affirm that I am the person listed under "Your name as program enrollee" and that all the information entered here is true and accurate to the best of my knowledge.
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Indicates Response Required