Phone: 1-800-585-6781 Fax: 1-606-783-5038
Morehead State University Office of Enrollment Services 100 Admission Center Morehead, KY 40351
ACT - 1530 SAT - 1487 TOEFL - 1487 FAFSA - 001976
The Admissions Application requires applicants to report all criminal convictions, other than minor traffic violations in order to assess the suitability of such applicants to the University community and identify any special conditions for enrollment.
This form is to certify that the following is a complete list of my convicted criminal offenses.
*Items in bold are required.
Applicant's Full Name:
Birth Date: (mm/dd/yyyy)
Last four digits of Social Security Number:
Driver's License Number:
Driver's License State:
or Other ID Number (State ID, driver's permit):
Felony or Misdemeanor:
Date of Offense: (mm/dd/yyyy)
Location of Offense (City & State):
Charging Law Enforcement Agency:
Please take a moment to review and acknowledge your understanding and acceptance of this agreement. All boxes must be filled-in and you must affix your electronic signature where indicated in order to continue.
By electronically signing the Criminal Background Release Form, I certify that the above listed information is a complete list of my criminal offenses. I authorize the Morehead State Police Department to review and verify my criminal history and release the findings to Enrollment Services, Office of Admissions.
I HEREBY AUTHORIZE any law enforcement agency and court to release the Morehead State University Police Department information on any and all of my charges.
I acknowledge and agree that the individual completing this electronic account application is the individual whose name the account is being requested.
By checking this box, I accept this agreement electronically:
Please type full name:
Today's Date: (mm/dd/yyyy)
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150 University Blvd. Morehead, KY 40351 • 1.800.585.6781
MSU is an affirmative action, equal opportunity, educational institution.