Prior Conduct Information And Release Form - Iupui Indiana

INDIANA UNIVERSITY-PURDUE UNIVERSITY INDIANAPOLIS

Prior Conduct Information and Release Form

Please complete and mail to:

Office of Undergraduate Admissions

425 University Boulevard CA 147

Indianapolis, IN 46202

IUPUI is committed to maintaining a safe environment for all members of the university community. As part of this commitment, the University requires applicants that have (1)

been convicted of any felony or misdemeanor such as simple battery or other convictions for behavior that resulted in injury to a person(s) or personal property or (2) who have

a history of formal disciplinary action at any college or university attended to disclose this information as a mandatory step in the application process. A previous conviction or

previous college disciplinary action does not automatically bar admission to the University, but it does require review. To help expedite this review, please ll out this form and

return it along with your disclosure statement to our o ce by certi ed mail as soon as possible to the address above. Please note, faxed copies will not be accepted.

Please print legibily in black ink.

Name___________________________________________________________________________________________________________________________

Last

First

Middle

Date of Birth (MM/DD/YY)___________________________________

University ID: (if known)______________________________________

Part I: (for those with criminal convictions)

Location

Conviction and Date

Disposition of Case

Incarcerated and Dates (y/n)

Probation and Dates (y/n)

Part II: (for those with a history of disciplinary action at a college or university)

Offense and Date

Location

Dates of Probation/Suspension

Disciplinary Action Taken

Attach a brief statement that explains the above activities, and why you should be permitted to enroll at IUPUI.

Please Note: If your records have been expunged (destroyed) pursuant to applicable law, you are not required to disclose this information. If you are unsure whether to answer yes, we

strongly suggest that you fully disclose all incidents to avoid any risk of cancellation/revocation of your application/o er of admission or dismissal if already enrolled.

Part III: Signature

This form must be signed by the applicant. By signing, you acknowledge:

I certify that all statements on this application are correct and complete. I understand that withholding pertinent information requested on this application or giving false information will make me ineligible for admission to

IUPUI or subject to cancellation of admission if admission has already been granted or dismissal if already enrolled. I also grant my permission to IUPUI to access any and all records (including, but not limited to, those records

held by law enforcement, judicial, university or college offices with records concerning my convictions or disciplinary actions) regarding the above incidents.

Full legal name (Signature) ________________________________________________________________ Date ________________________