• NYS Legislative Internship Release of Individual Student Conduct/Disciplinary Record [-- SAMPLE FORM ONLY FOR STUDENT REVIEW]

    Section A completed by the student; Section B completed by Community Standards, Office of the Dean of Students
  • Date of request
     - -
    2 digit month, 2 digit day, 4 digit year

  • This Release of Individual Student Conduct/Disciplinary Record is for the student named below in relation to their application for the New York State Legislative Internship Program Application in the Spring term of this academic year.

    Your comments may be used in the preparation of the University at Albany Campus Liaison and Review Committee evaluation of this student. The importance of this form both to the student and to the reputation of the University at Albany cannot be over-emphasized. Prompt completion of this form will be appreciated by both the applicant and the Committee. Our evaluation cannot be prepared until this report is received.

  • Section A

    Completed by the student
  • Statement of Student*
  • Permission to Release Student Conduct/Disciplinary Record*

  • Section B

    To be completed by Community Standards, Office of the Dean of Students
  • Has the student listed above ever been placed on probation, been suspended, or expelled from the University at Albany?*
  • Does the student listed above have any pending disciplinary charges?*

  • By submitting this form, you are certifying that all information provided is accurate.

  • SAMPLE FORM ONLY

    This form is provided for student information only. Do not complete this form.

  • Should be Empty: