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Disciplinary Clearance Form

This document is a disciplinary clearance form for students applying to the Semester at Sea program. It requires the signature of the student to consent to the release of their disciplinary record. It must then be completed by the appropriate official at the student's home institution to disclose any prior judicial sanctions or violations. The official certifies that the information provided is correct to the best of their knowledge by signing and dating the form.

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Utkarsh Bansal
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101 views2 pages

Disciplinary Clearance Form

This document is a disciplinary clearance form for students applying to the Semester at Sea program. It requires the signature of the student to consent to the release of their disciplinary record. It must then be completed by the appropriate official at the student's home institution to disclose any prior judicial sanctions or violations. The official certifies that the information provided is correct to the best of their knowledge by signing and dating the form.

Uploaded by

Utkarsh Bansal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Disciplinary Clearance Form

To The Student: This form must be completed by the Study Abroad Office, Judicial Affairs Office, the Dean
of Students, or the appropriate administrative official at your home institution. Your signature provides
consent for release of this information from the point of application until the starting date of the semester. It
is your responsibility to update our office immediately if you have new violations or changes in your
disciplinary status after initially submitting this form.

Student's printed name: ________________________________

Student's signature: _______________________ Voyage: Fall _____ Spring _____

To College or University Official: The student named above has applied to participate in Semester at
Sea program. If selected, the student will be expected to enroll in a full academic program, carrying a
minimum of 12 credit hours. We would appreciate a confidential statement evaluating this student's record
at your institution. While prior disciplinary history does not preclude a student's participation, this
information is taken into consideration during review and must be submitted in order for the student to be
evaluated for admission to the program. Recognizing that a student's status can change from the
completion of this form until the time of departure, we must receive notification of any new
violations or changes to this record.

Please use the comment section for further clarifications if necessary.

Name of home institution: _____________________________ Dates of attendance:___________

Please check one box only.

 This student has not received a judicial sanction at this institution.

 This student is not currently under active judicial sanction, but has been previously sanctioned
(describe below).

 This student is currently under judicial sanction (describe below).

__________________________________________________________________________
Violation/Adjudication Date Sanction with Effective Dates

__________________________________________________________________________
Violation/Adjudication Date Sanction with Effective Dates

__________________________________________________________________________
Violation/Adjudication Date Sanction with Effective Dates

__________________________________________________________________________
Violation/Adjudication Date Sanction with Effective Dates

__________________________________________________________________________
Violation/Adjudication Date Sanction with Effective Dates

- OVER -
Additional Comments
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Certification – Please sign below to certify that the above information is correct to the best of your
knowledge.

_________________________________________________________________________
Your Printed Name Title

_________________________________________________________________________
Institution/Department Contact Phone Number

_________________________________________________________________________
Signature Date

Please return all materials to


Institute for Shipboard Education |Semester at Sea
Colorado State University
Campus Delivery 1587
Fort Collins, CO 80523-1587
Fax: (970) 237-3207

OR email to [email protected]

(800) 854-0195
www.semesteratsea.org

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