College of Education & Science

Teacher Education

Applicant Conduct Review Statement

Applicant Full Name (Print) / (Maiden)

Respond to EACH item checking YES or NO. If an arrow () follows your response, follow the instruction given and attach any/all requested materials to your application, numbering the attachments with the number of the applicable item. If there is no response to any item, or if the required attachments do not accompany your applications, your application will not be accepted.

Have you ever been convicted of a crime?  TO properly answer this question, the term CRIME includes a misdemeanor, a gross misdemeanor, a felony or a charge that resulted in a stay of imposition of sentence. IT DOES NOT INCLUDE PETTY MISDEMEANNORS.

The term CONVICTION includes a finding of guilt by a jury or judge, an admission of guilty or plea of guilty, or a no contest or Alford plea (a plea without an admission of guilt). You are considered convicted whether or not the sentence is stayed or executed.

If your criminal conviction has been expunged by a Court, you must still answer “YES” to this question, unless the Court Order issuing the expungement specifically states that you do not have to disclose your conviction.

YES If you answered “YES” to this item, attach material indicating the crime of which you were convicted, the dates of your conviction or plea of guilty, the date you were sentenced, and the sentenced imposed. If you have been discharged from probation, include information regarding your discharge from probation. If you are currently on probation. provide the name and telephone number of your probation officer.

Is any criminal charge currently pending against you in any state?

YES If you answered “YES”, attach material explaining the action or charges, location, dates, and agency involved.

Have you ever been a party to a civil settlement, award or agreement of any kind that involved an allegation concerning your sexual conduct?

YES If you answered “YES”, attach material explaining the action or charges, location, dates, and agency involved.

WARNING: FAILURE TO ANSWER ANY OF THESE QUESTIONS, OR FAILURE TO PROVIDE THE INFORMATION REQUESTED COULD LEAD TO DENIAL OF ADMISSION TO YOUR DESIRED PROGRAM.

CERTIFICATION OF INFORMATION

I certify that all information contained on and submitted with this conduct review statement is, to the best of my knowledge, true and accurate. I understand that any intentional misrepresentation of facts or falsification of statements or accompanying documents may result in dismissal from any and all professional programs.

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Signature of ApplicantDate

ED201 Folder/Conduct Review Formrev 7/2015