QUESTIONS:

If yes to any of the following, please provide further documentation. Yes No

1. Has the student ever been found responsible in a Title IX or related disciplinary proceeding for sexual, interpersonal or other acts of violence?
2. Has the student ever been criminally convicted for sexual, interpersonal or other acts of violence?
3. Did the student have a Title IX or related disciplinary proceeding for sexual, interpersonal or other acts of violence when the student left the institution?

INSTITUTION OFFICIAL'S SIGNATURE: ___

DATE: ___

ONWARD. UPWARD. FORWARD.