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Indiana University Bloomington

Undergraduate Department

 

* Required Fields
Criminal Activity Disclosure Form

Student Information

*First Name *Last Name:
 Middle Name  Former Name:

If you attended IUB under another name, you must submit a name change to the Office of the Registrar.

 University ID:  Social Security Number: (last 4 digits)
*Street Address:  Telephone: (include area code)
*City:  Preferred Cell:
*State: *E-mail Address:
*Zip Code: *Date of Birth:
*Country:

*I intend to enroll:   *Program Level:  

Last semester/summer session attended IU:  Semester: Year:

If you have completed any college coursework since last enrolled at IU, please complete the following:
College:   Dates:   Degree:  

Criminal Activity Disclosure

We are committed to maintaining a safe learning environment.  As part of that commitment, we require applicants who have been charged with or convicted of a misdemeanor or felony, or who have engaged in behavior that resulted in mental or physical injury to person(s) or personal property (including for example, but not limited to, behavior that led to a restraining order against you), to dis-close that information.  A previous conviction or previous conduct of the sort identified here would not automatically preclude ad-mission to IU but does require review.  Also, if additional legal charges or injurious behaviors occur prior to matriculation at IU, you must provide updated information to the Office of Admissions, 300 N Jordan Avenue, Bloomington, IN 47405, before attending classes.  The committee must review the new information prior to your matriculation at IU.

*Have you ever been charged with or convicted of a misdemeanor or felony?      

*Have you engaged in behavior that resulted in mental or physical injury to person(s) or personal property?      

If yes to either question, please enter the following documentation: a brief explanation (in English) of the conviction or problematic conduct, the dates and court disposition, the location (city, state, and country) and the impact the incident(s) had on you.  Your signature here gives Indiana University permission to access pertinent criminal records.  Additional information may be requested and additional time may be required to review this information.

*Signature:   Date: 4/17/2014