Duty to Report Arrests & Convictions Form

Please complete the information below. ALL FIELDS ARE REQUIRED.

Name as it appears in the Student Information System (SIS)

Last Name

First Name

Middle Initial

Email Address

Phone Number

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Have you ever been convicted of (or is any charge now pending against you for) any violation of federal, state, local, or international law? You do not need to report minor traffic violations that did not result in injury to others. Charges related to reckless driving and driving under the influence of alcohol or other drugs are not "minor traffic violations" and must be reported.

Yes

Please describe the incident(s) that led to your arrest:

Date of incident(s):

Date of incident(s):
Date of incident(s):

Location(s) of incident(s) - city, state, country

Location(s) of incident(s) - city, state, country
Location(s) of incident(s) - city, state, country

Exact charge(s) filed:

Exact charge(s) filed:
Exact charge(s) filed:

Court where charge(s) filed:

Court where charge(s) filed:
Court where charge(s) filed:

Date of next or last hearing:

Have you been found guilty?

Yes

If Yes, describe the sentence or action imposed by the Court (e.g., period of actual or suspended incarceration, educational programming, fine, etc.):

Are you currently on probation or parole?

Yes

Signature (PRINT NAME):

Date:

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