Undergraduate Request Form For Readmission (Page 2 of 2) in pdf

AFETY AND SECURITY

Student ID# ___________________

For the safety and security of the UND community, all students making application to the University of North Dakota MUST ANSWER ALL OF THE

FOLLOWING QUESTIONS. An affirmative response to any of these questions will not automatically prevent admission, but you will be asked by the university

to provide additional information. The information will be reviewed by a campus committee for possible effects on campus safety. Any falsification or omission

of the data may result in denial of admission, revocation of admission, dismissal or other appropriate sanctions.

Have you ever pled guilty (or no contest) to or been convicted of any felony?



Yes

(If yes, please indicate ALL states, cities, counties and dates of convictions. Attach an additional sheet if necessary.)

State ______________________ City______________________ County ______________________ Date ______________________

Within the past 10 years, have you pled guilty (or no contest) to or otherwise been convicted of a misdemeanor crime involving violence or the threat of

violence in any court? ("Crime of violence" means as offense in which physical force was used, attempted or threatened against the person or property of

another or by the nature of the offense it involves substantial risk that physical force may be used against a person or property of another. Examples of

crimes of violence include, but are not limited to, abuse, arson, assault (including sexual assault or domestic violence), battery, breaking and entering,

burglary, criminal mischief or vandalism, harassment, homicide, menacing, reckless endangerment, stalking, terrorizing and unlawful restraint or

imprisonment.



Yes

(If yes, please indicate ALL states, cities, counties and dates of convictions. Attach an additional sheet if necessary.)

State ______________________ City______________________ County ______________________ Date ______________________

Are you currently required to register as a sex offender in any state?



Yes

(

If yes, please indicate ALL states, cities, counties and dates of convictions. Attach an additional sheet if necessary.)

State ______________________ City______________________ County ______________________ Date ______________________

Have you been dismissed or suspended from a college or university for disciplinary reasons within the last 5 years ("Dismissed for disciplinary reasons"

means a permanent separation from an institution due to conduct or behavior. "Suspended for disciplinary reasons" means a sanction imposed for

disciplinary reasons that results in a student leaving school for a fixed period but not permanently.)



Yes

(If yes, please indicate ALL states, cities, countries and dates of convictions. Attached additional sheet if necessary)

*If you answered yes to any of the above, please write a personal narrative below (or attach an additional sheet if necessary) explaining the nature of the

offenses(s) and surrounding circumstances. A yes answer to any of the above questions may require additional documentation which must be received 30

days prior to the term for which you are seeking admission.

________________________________________________________________________________________________________

Contact the Office of Admission at 1-800-225-5863 or 701-777-3821 with questions you may have regarding this

form. Go to to view the list

of NDUS academic programs which require further criminal history background checks. These may include nationwide FBI criminal history background checks or a criminal history background check

which may be a North Dakota BCI check, nationwide check or check of another state or multiple jurisdictions.

REQUIRED SIGNATURE

I understand the information presented on this form will be used in evaluation of my application for admission to UND. I certify that all statements are complete

and true as of this date. If this information changes, I will notify the Office of Admission of the changes and understand that my admission status will be re-

evaluated at that time.

Signature of Student: _________________________________________________________________________ Date: ______________________________

Name of Student (Please Print) ______________________________________________________________ Date: ______________________________

*NOTE: This information is requested for statistical purposes only and will not affect the status of your application. The information will not be used in a discriminatory manner

and your response is voluntary.

**Disclosure of your Social Security Number is voluntary. Social Security Numbers are used as an Individual ID number for record keeping and administrative purposes. Failure

to provide a SSN may cause delays in administrative services such as financial aid processing

Updated 2/10/16

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