Morehead State University Criminal Background Release Form

 

Please process your request by the following dates:

                            Summer I             Deadline:  May 20, 2011
                            Summer II           Deadline:  June 17, 2011
                            Fall 2011              Deadline:  August 5, 2011

 

The Undergraduate Admissions Application requires applicants to report all criminal convictions, other than minor traffic violations in order to assess the suitability of such applicants to the University community and identify any special conditions for enrollment.

 

This form is to certify that the following is a complete list of my convicted criminal offenses.

*Items in bold are required.

Applicant's Full Name                                           

Birth Date                                                              

Social Security No. (Last four digits only)         

Mailing Address                                                    

City, State, Zip                                                      

Telephone Number                                               

Driver's License Number                                                
Driver's License State                                                    
or
Other ID Number (State ID, driver's permit, etc...)     

 

 

Offense 1                                                            
Felony or Misdemeanor                                         
Date of Offense                                                     
Penalty                                                                  
Location of Offense (City & State)                         
Charging Law Enforcement Agency                       

 

Offense 2                                                            
Felony or Misdemeanor                                         
Date of Offense                                                     
Penalty                                                                  
Location of Offense (City & State)                         
Charging Law Enforcement Agency                       

 

Offense 3                                                           
Felony or Misdemeanor                                         
Date of Offense                                                     
Penalty                                                                  
Location of Offense (City & State)                         
Charging Law Enforcement Agency                       

 

Offense 4                                                            
Felony or Misdemeanor                                         
Date of Offense                                                     
Penalty                                                                  
Location of Offense (City & State)                         
Charging Law Enforcement Agency                       

 

Offense 5                                                            
Felony or Misdemeanor                                         
Date of Offense                                                     
Penalty                                                                  
Location of Offense (City & State)                         
Charging Law Enforcement Agency                       

 

Additional Convictions                                        

Please take a moment to review and acknowledge your understanding and acceptance of this agreement.   All boxes below must be filled-in and you must affix your electronic signature where indicated in order to continue.  

By electronically signing the Criminal Background Release Form, I certify that the above listed information is a complete list of my  criminal offenses.  I authorize the Morehead State University Police Department to review and verify my criminal history and release the findings to Enrollment Services, Office of Admissions.

I HEREBY AUTHORIZE any law enforcement agency and court to release to the Morehead State University Police Department information on any and all of my charges. 

 

                            Applicant authorization expires six months of receipt of release form.

 

I acknowledge and agree that the individual completing this electronic account application is the individual in whose name the account is being requested.

I accept this agreement electronically by

    1.  Typing "I Accept" in the box to the right.                   

    2.  Typing my full name in the box to the right.               

    3.  Typing today's date in the box to the right.               

Please note that submission of this form constitutes an electronic signature, which is used in lieu of your handwritten signature.   Your electronic signature is consent that all information provided is correct and that you agree to the terms.

 

Note:  The following form is not submitted via a secure web site.  If you have concerns about the privacy of your information, you may print the form and send it to:  Morehead State University, Office of Enrollment Services, 100 Admissions Center, Attn:  Myra Mayse, Morehead, KY 40351.