Fillable Judicial Review Form 3-2017 (State University of New York at Farmingdale)

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Judicial Review Form 3-2017 (State University of New York at Farmingdale)

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STATE UNIVERSITY OF NEW YORK
Overseas Academic Programs
JUDICIAL REVIEW FORM FOR STUDY ABROAD
The State University of New York requires a judicial review of all applicants for its study abroad programs.
It is necessary for us to be informed of any judicial record that exists for any participant. The existence of
judicial records at the participant’s home university does not necessarily mean denial of admission to a
program; however, the information must be reviewed by the Study Abroad Office on the campus
responsible for the program in order for a determination to be made. Each applicant, regardless of home
campus, is required to provide this authorization even if there is no judicial record. Students must also
inform their home campus Study Abroad Office about their intention to study abroad.
Instructions for the Student: Please complete Section I of this form and then take the form to the Judicial
Officer on your home campus.
Instructions for the office of the Dean of Students: The student named on this form has authorized
release of his/her judicial record to the Office of International Education and Programs office. Please
complete the second section of this form and then return both pages of this to us directly by mail or fax
or as a PDF scan via email to the address/fax/email at the end of this form. A prompt response is
appreciated.
I. To Be Completed by the Student:
____________________________ ____________________________ ___________________
Last Name First Name RAM/Campus ID#
_______________________________________ _______________________________________
Home Campus Study Abroad Program & Administering Campus
Have you ever been convicted of a felony? _____ yes _____ no
If yes is checked, submit an explanation or ask to speak with the Study Abroad Advisor.
Have you ever been suspended, dismissed, or expelled from a college or university? _____yes _____ no
Dean Esnes-Johnson 631.420.2104
Name of Dean of Students on Your Home Campus Phone Number for Dean of Students
johnsot@farmingdale.edu 631.420.2613
Email Address for Dean of Students Fax Number for Dean of Students
Please give your consent by agreeing with your signature to the statement below.
Under the provisions of the Family Education Rights and Privacy Act, I authorize the judicial affairs officer
named above to provide documentation and discuss all information related to any judicial affairs review
on the campus at which I am matriculated with the appropriate Study Abroad Office staff members and,
if appropriate, with the associated faculty program director, for the purpose of determining my
participation in a study abroad program.
____________________________________ ____________________________
Student Signature Date Release Signed
_____________Date This Release Expires and Is No Longer Valid. (Recommended: day your semester abroad ends.)
Last Updated January 2017
Page 1 of 2
II. To Be Completed by the Office of the Dean of Students
________________________________________ _______________________________________
Student’s Last Name Student’s First Name
1. _______ The student named above and on the reverse side of this form has not received a
judicial sanction (probation or higher) on our campus.
2. _______ The student named above and on the reverse side of this form has received a judicial
sanction (probation or higher) on our campus.
Effective Dates: __________________________________________
Level of Sanction: ________________________________________
Violation:______________________________________________________________________
______________________________________________________________________________
Other Remarks:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________ ________________________________
Printed Name of Individual Authorized to Complete This Form Signature
______________________________________________ ________________________________
Title Date
Please return both pages of this form directly to the Office of International Education and
Programs at:
Office of International Education and Programs
Study Abroad Office, Laffin Hall Room 320
studyabroad@farmingdale.edu
(t)631-794-6362 (f)631-420-2780
Page 2 of 2
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Judicial Review Form 3-2017 (State University of New York at Farmingdale)

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Completed 26 July 2020

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