Safety and Security Information
All students making application must answer the following questions. An affirmative response to any of these questions will not automatically prevent
admission, but you will be asked to provide additional information. The information, then, will be reviewed by a campus officer or committee charged with that
responsibility. Fabrications or omission of information may result in a denial of admission, revocation of admission, dismissal, or other appropriate sanction.
1. Have you ever pled guilty (or no contest) to or been convicted of any felony? (This EXCLUDES juvenile court proceedings.)
Yes
No
2. Within the past 10 years, have you pled guilty (or no contest) to or otherwise been convicted of a misdemeanor crime involving violence or the threat of violence
in any court? (“Crime of violence” means an offense that involves substantial risk that physical force may be used against a person or property of another.
Examples of crimes of violence include, but are not limited to, abuse, arson, assault (including sexual assault or domestic violence), battery, breaking and
entering, burglary, criminal mischief or vandalism, harassment, homicide, menacing, reckless endangerment, stalking, terrorizing and unlawful restraint or
imprisonment) (This EXCLUDES juvenile court proceedings.)
Yes
No
3. Are you currently required to register as a sex offender in any state? (
This INCLUDES juvenile offenders who are required to register
.)
Yes
No
4. Have you been dismissed or suspended from a college or university for disciplinary reasons within the past 5 years? (“Dismissed for disciplinary reasons”
means a permanent separation from an institution due to conduct or behavior. “Suspended for disciplinary reasons” means a sanction imposed for disciplinary
reasons that results in a student leaving school for a fixed period but not permanently.) (This EXCLUDES suspension based on academic performance.)?
Yes
No
Disclosure of Social Security Number is Voluntary
Failure to provide a Social Security Number may cause delays in administrative services, such as financial aid processing and receiving Federal tax
information.
International students: Please provide a U.S. Social Security Number if you have been assigned one. If you are entering the U.S. for the first time, please
leave the field blank.
Equal Opportunity Policy Statement
It is the policy of the North Dakota University System that no person in the United States shall be discriminated against because of race, religion, age,
color, gender, disability, national origin, sexual orientation, gender identity, genetic information, creed, marital status, veteran’s status, political belief or
affiliation and the equal opportunity and access to facilities shall be available to all. This policy is particularly applicable in the admission of students in
all colleges, and in their academic pursuits. It also is applicable in the University-owned or University-approved housing, food services, extracurricular
activities and all other student services. It is a guiding policy in the employment of students either by the University System or by outsiders through the
University System and in the employment of faculty and staff. Concerns regarding the Title IX, Title VI, ADA, and Section 504 of the Rehabilitation Act of
1973 may be addressed to the Office of Civil Rights, U.S. Dept. of Education, 8930 Ward Parkway, Suite 2037, Kansas City, MO 64114-3302, email:
OCR.KansasCity.ed.gov, or your on-campus Affirmative Action/Equal Opportunity Officer, Marc Wachtfogel, HR Director,
marc.wachtfogel@minotstateu.edu
, 701-858-4610.
I understand the information presented on this form will be used in evaluating my application for admission to Minot State University. I certify that all my
statements are complete and true as of this date and that any falsification or willful omission of information submitted for an application may result in
delays, sanctions, or criminal charges. If any information changes, I will notify Minot State University of the changes and understand that my admission
status may be reevaluated at that time.
Please return this form to the Minot State University Graduate School, via US mail or email. If you email the
form you understand it is not a secure submission.
Minot State University
Graduate School
500 University Ave W
Minot ND 58707
Email: graduate@minotstateu.edu
UPDATED: 12/6/17
By signing below, I certify that the information supplied by me on this application is true and correct to the best of my knowledge.
Signature of student
Today’s Date (MM/DD/YYYY)
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