1. Do you have criminal charges pending against you?

Yes No

2. Have you been convicted of, pled guilty to, or pled no contest to any crime involving:
a. Acts of a violent or sexual nature in the past? Yes No
b. Stalking? Yes No
c. Other felony crime? Yes No

3. Have you been disciplined, suspended or placed on probation for any

reason, including scientific misconduct, in any previous instructional or
Yes No
administrative position, including at any previous high school, two year
college or four year college or university?
If Yes, please provide additional information regarding date and incident:

4. At the time you left your previous institution, were you the subject of a
pending proceeding of any sort that could have resulted in disciplinary
Yes No
measures, suspension, expulsion or probation? Are you currently the
subject of this kind of proceeding at your current institution/university?
If Yes, please provide additional information regarding date and incident:

By signing this form, I agree that the information contained within is accurate.
Applicant Signature:
Date: