Judicial Clearance Form

Judicial Clearance Form
Section A.

To be completed by the student
Name*

First NameMiddle NameLast Name
Student ID*
e.g., 001234567
Email*
example@albany.edu
STATEMENT OF STUDENT:*
By signing (typing your legal name) in the space below, you are certifying that all information on this form is correct and that you are the person completing this application.

When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification.
Signature*
Date*

MonthDayYear
Date
Judicial Affairs Email
communitystandards@albany.edu

Section B.

To be completed by the Community Standards, Office of the Dean of Students
Concerning {name} (ID #: {studentId4}) in regard to personal qualifications for medical school and the practice of medicine.
Your comments may be used in the preparation of the University at
Albany Pre-Health Advisory 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, because our evaluation cannot be prepared until this report is received. Thank you very much indeed for your help.
STATEMENT OF STUDENT:*
Has the student ever been placed on probation, suspended, or expelled?*

YesNo
Please explain.*
Are any disciplinary charges pending?*

YesNo
Please explain.*
Name*

First NameLast Name
Position*
Address*
Office of the Dean of Students, Campus Center 137 1400 Washington Avenue Albany, NY 12222
By signing (typing your legal name) in the space below, you are certifying that all information on this form is correct and that you are the person completing this application.

When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Section A.