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MSU Home :: Future Students :: Criminal Background Form

Morehead State University Criminal Background Release Form

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:  

Mailing Address:   

 

City:  

State:  

Zip Code:  

Phone Number:  

Driver's License Number:  

Driver's License State:  

or 
Other ID Number (State ID, driver's permit):  

Offense 1 

Felony or Misdemeanor:  

Date of Offense:  (mm/dd/yyyy)

Penalty:   

Location of Offense (City & State):  

Charging Law Enforcement Agency:   

Offense 2 

Felony or Misdemeanor:  

Date of Offense:  (mm/dd/yyyy)

Penalty:   

Location of Offense (City & State):  

Charging Law Enforcement Agency:   

Offense 3 

Felony or Misdemeanor:  

Date of Offense:  (mm/dd/yyyy)

Penalty:   

Location of Offense (City & State):  

Charging Law Enforcement Agency:   

Offense 4 

Felony or Misdemeanor:  

Date of Offense:  (mm/dd/yyyy)

Penalty:   

Location of Offense (City & State):  

Charging Law Enforcement Agency:   

Offense 5 

Felony or Misdemeanor:  

Date of Offense:  (mm/dd/yyyy)

Penalty:   

Location of Offense (City & State):  

Charging Law Enforcement Agency:   

Additional Convictions:   

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)

 

  • Please note that submission of this form constitutes an electronic signature, which is used in lieu of your handwritten signature. Your electronic signature is consent that all information provided is correct and that you agree to the terms. 
  • Applicant authorization expires six months of receipt of release form. 
  • The following form is not submitted via a secure website. If you have concerns about the privacy of your information, you may print this form and send it to: Morehead State University, Office of Enrollment Services, 100 Admissions Center, Attn: Myra Mayse, Morehead, KY 40351.

 

 

 

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