Fillable Compliance Clery Act Leased or Rented Facility Form (Northwestern State University)

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Compliance Clery Act Leased or Rented Facility Form (Northwestern State University)

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University Safety &
Compliance
Clery Act Leased or Rented Facility Form
This form is to be completed for University-related travel. Information provided will assist the University in meeting
requirements under the Clery Act. Only complete if there is a written agreement for the space used (such as a
classroom or office space). Note, if we have an agreement to send students to a location for a particular program,
but that written agreement is only for the program and not for the physical space, then we do not have control of
the location.
Group Name/Class:
Travel Contact:
Name Title
Department Phone Email
Leased or Rented Facility Information:
Name:
Address:
Dates: / / through / /
Law Enforcement Agency Having Jurisdiction for the facility:
Note: Your facility may be able to provide you with this information.
Agency Name:
Agency Mailing Address:
Phone Number: ______
Agency Email Address (if known):
Email completed form to:
calistej@nsula.edu
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Compliance Clery Act Leased or Rented Facility Form (Northwestern State University)

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Completed 24 August 2020

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