A registrant shall complete, sign, and date a registration statement form with a supervising authority. A registration statement includes the following information supplied by the registrant: Registrant's full name; Address as follows: Registrant's address, including county; or If on work release or temporary leave, the address of the State or local correctional facility granting work release or temporary leave; Registrant's fingerprints obtained at the time of registration by, or at the direction of, the supervising authority; For nonresident registrants: The name of the registrant's employer or school; and The address, including county, of the registrant's work site or site of school attendance; Registrant's signature; and Date signed. A registration statement includes the following information supplied by the supervising authority: Registrant's photograph obtained at the time of registration; Registrant's Social Security number, as required under Criminal Procedure Article, §11-706(a)(7), Annotated Code of Maryland; Any aliases used by a registrant, including dates of birth and Social Security numbers; For each crime for which the registrant is required to register: Name of the crime, including statutory citation if applicable and available; Date of conviction; Name of Maryland court and county, or other court and location, where the registrant was convicted; Date the crime was committed; and Victim's age at the time the crime was committed; Registrant category, or multiple categories if applicable; Date of release; Term of registration; For a sexually violent predator: Identifying factors, including scars, marks, tattoos, and other significant physical characteristics; The prior sexually violent offense or offenses that are the basis for the proceeding under Criminal Procedure Article, §11-703, Annotated Code of Maryland; and Dates and places of treatment received for a mental abnormality or personality disorder; Information required in order to reimburse supervising authorities for the cost of processing registration statements under Criminal Procedure Article, §11-713(3), Annotated Code of Maryland; and Any attachments necessary to facilitate the accurate and timely registration of the registrant.