Judicial Review Form For Overseas Study printable pdf download

JUDICIAL REVIEW FORM FOR OVERSEAS STUDY

The State University of New York requires a judicial review of all applicants for its study abroad

programs. It is necessary for us to be informed of any judicial record that exists for any participant. The

existence of judicial records at the participant’s home university does not necessarily mean denial of

admission to a program; however, the information must be reviewed by the Study Abroad and Exchange

Office on the campus responsible for the program in order for a determination to be made. Each

applicant, regardless of home campus, is required to provide this authorization even if there is no judicial

record. Students must also inform their home campus Study Abroad and Exchange Office about their

intention to study overseas.

Instructions for the Student: Please complete Section I of this form and then take the form to the

Judicial Officer on your home campus. Please pick up the completed form up from the Judicial Officer

on your home campus then scan it and upload to your SBU Study Abroad application as part of your

Study Statement.

Instructions for the judicial officer: The student named on this form has authorized release of his/her

judicial record to the Study Abroad and Exchange Office at Stony Brook University. Please complete the

second section of this form and then return both pages to the student.

I. To Be Completed by the Student:

____________________________

___________________

Last Name

First Name

Campus ID#

_______________________________________

Home Campus

Program Abroad & Administering Campus

Have you ever been convicted of a felony? _____ yes _____ no

If yes is checked, submit an explanation or ask to speak with a Study Abroad/Exchange Advisor at SBU

Have you ever been suspended, dismissed, or expelled from a college or university? _____ yes _____ no

If yes is checked, submit an explanation or ask to speak with a Study Abroad/Exchange Advisor at SBU

_____________________________________________________________________________________

Name of Judicial Officer on Your Home Campus

Phone Number for Judicial Officer

________________________________________________________________________________________________________

Email Address for Judicial Officer

Fax Number for Judicial Officer

Please give your consent by agreeing with your signature to the statement below.

Under the provisions of the Family Education Rights and Privacy Act, I authorize the judicial affairs

officer named above to provide documentation and discuss all information related to any judicial affairs

review on the campus at which I am matriculated with the appropriate Study Abroad Office staff

members and, if appropriate, with the associated faculty program director, for the purpose of determining

my participation in a study abroad program.

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Judicial Review Form For Overseas Study