Information Request Form
Sex Offender Information Request Form
Please print, complete, and submit this form to the Public Safety Office:
Middlesex Community College
Request for Sex Offender Information
The Public Safety Office, at both the Bedford and Lowell Campuses may have available information on certain individuals classified as Level 2 (moderate risk) or Level 3 (high risk) sex offenders in the Commonwealth of Massachusetts. The College shall release sex offender information to members of the College community who request it.
In response to your request for sex offender information, you will receive a report which indicates the name of the offender, the home address, the work address, the offense(s) and date(s) for which the offender was convicted/adjudicated, and the offender's vital statistics, including age, sex, race, height, and weight. A photograph will be provided if available.
The information the College has in its possession was provided to it by either local law enforcement in the town/city in which the college is located or the Sex Offender Registry Board. The College does not have access to or maintain a complete list of all registered sex offenders who may be attending or working at the College. For a complete list of all registered Level 2 or Level 3 sex offenders who may attend or work at the College, you are advised to contact your local police department or the Sex Offender Registry Board, P.O. Box 4547, Salem, MA 01970-4547, (978) 740-6400, https://www.mass.gov/orgs/sex-offender-registry-board.
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To be completed by party requesting information.
NAME OF REQUESTER:
ADDRESS:
CITY/TOWN, STATE & ZIP:
TELEPHONE:
DATE OF BIRTH:
DATE/TIME OF REQUEST:
I request from the College’s Police/Security Department information pertaining to sex offenders attending or employed at the College or living in the vicinity of the College’s campus locations. I acknowledge that I am 18 years of age or older and am seeking this information for my own protection or for the protection of a child under the age of 18 or another person for whom I have responsibility, care or custody.” M.G.L. c. 6, § 178J(a)(4).
SIGNATURE OF REQUESTER: ___________________________________________
WARNING
SEX OFFENDER REGISTRY INFORMATION SHALL NOT BE USED TO COMMIT A CRIME OR TO ENGAGE IN ILLEGAL DISCRIMINATION OR HARASSMENT OF AN OFFENDER. ANY PERSON WHO USES INFORMATION DISCLOSED PURSUANT TO M.G.L. C. 6, §§ 178C – 178P FOR SUCH PURPOSES SHALL BE PUNISHED BY NOT MORE THAN TWO AND ONE HALF (2 ½) YEARS IN A HOUSE OF CORRECTION OR BY A FINE OF NOT MORE THAN ONE THOUSAND DOLLARS ($1000.00) OR BOTH (M.G.L. C. 6, § 178N). IN ADDITION, ANY PERSON WHO USES REGISTRY INFORMATION TO THREATEN TO COMMIT A CRIME MAY BE PUNISHED BY A FINE OF NOT MORE THAN ONE HUNDRED DOLLARS ($100.00) OR BY IMPRISONMENT FOR NOT MORE THAN SIX (6) MONTHS (M.G.L. C. 275, § 4).