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SQ 1 Fillable Web

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U.S.A. forms for Great Falls College Montana State University

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changing lives - achieving dreams
Our Mission is to foster the success of our students and their communities
through innovative, flexible learning opportunities for people of all ages,
backgrounds, and aspirations resulting in self-fulfillment and
competitiveness in an increasingly global society.
GREAT FALLS COLLEGE MSU
OFFICE OF ADMISSIONS
2100 16th Avenue South, Great Falls, MT 59405
[406] 771.4300 or [800] 446.2698 fax: [406] 771.4329
www.gfcmsu.edu
Dear Prospective Student,
Thank you for your interest in Great Falls College MSU of the Safety and Security questions on the Admissions
Application. The safety and security of our building, faculty, staff and students is foremost in our minds. In order for our
office to further evaluate and process your application you must complete the following steps and return any requested
documentation.
Complete the Safety and Security Questionnaire included with this letter
SIGN and DATE the Consent to Release Information which is located on the Safety and Security Questionnaire.
This release will pertain to arrests, convictions, probation/parole status and any treatment/rehabilitation.
Attach record searches or sentencing information from the court(s) for each felony. If you do not have your
sentencing paperwork, you may also provide a full Montana criminal history that can be obtained online at:
https://doj.mt.gov/enforcement/background-checks/. If your conviction(s) occurred outside the state of Montana
or was a Federal conviction, you will need to contact each state or Federal court to obtain this information.
Criminal histories downloaded from the Montana Department of Corrections Correctional Offender Network
Search website will not fulfill this requirement. Please note that failure to submit this information will delay
your admission process.
A minimum of three (3) letters of reference or support from non-family members if no longer on probation
and/or parole supervision (See Letter of Recommendation Form)
A personal interview after above items have been provided. *Please note, this will not be scheduled until the
above has been completed
Our Admissions Committee typically meets the first and third weeks of the month. We will review the information that
you provide at this time. If the committee feels additional information is required prior to processing your will be
informed in writing. *Please note: this process can take 4-6 weeks so timely completion of your requirements is
essential. If you have questions or concerns about this process please contact Brittany Budeski at 406-771-4309 or
brittany.budeski@gfcmdu.edu. Please keep this letter for your records.
Sincerely,
Brittany Budeski
Director of Admissions and New Student Services
Enc: SQ1
changing lives - achieving dreams
Our Mission is to foster the success of our students and their communities
through innovative, flexible learning opportunities for people of all ages,
backgrounds, and aspirations resulting in self-fulfillment and
competitiveness in an increasingly global society.
GREAT FALLS COLLEGE MSU
OFFICE OF ADMISSIONS
2100 16th Avenue South, Great Falls, MT 59405
[406] 771.4300 or [800] 446.2698 fax: [406] 771.4329
www.gfcmsu.edu
Safety and Security Questionnaire - Checklist
On your application for admission to the Great Falls College MSU you answered in the affirmative to the
“Safety and Security” question - Have you ever been convicted of a felony (please include instances of
deferred sentencing)?
The safety and security of our building, faculty, staff and students is foremost in our minds. In order to evaluate
your application for admission or readmission, please complete the following questionnaire for every felony
conviction.
The following lists the required information and/or items necessary to complete the process. Please initial
next to each item when you have completed it. After all required items are returned, please sign at the
bottom of the page and return to the Admissions Office. All items turned into the Admission Committee as
part of the Safety and Security process become property of Great Falls College MSU and will not be returned to
the student.
______ A completed Safety and Security Questionnaire
______ A signed and dated Consent to Release of Information located on the Safety and Security Questionnaire
regarding arrests, convictions, probation/parole status, and treatment/rehabilitation
______ Attach record searches or sentencing information from the court(s) for each felony. If you do not have
your sentencing paperwork, you may also provide a full Montana criminal history that can be obtained
online at: http://www.doj.mt.gov/enforcement/criminaljustice/backgroundchecks.asp. If your
conviction(s) occurred outside the state of Montana or was a Federal conviction, you will need to
contact each state or Federal court to obtain this information. Criminal histories downloaded from the
Montana Department of Corrections Correctional Offender Network Search website will not fulfill this
requirement. Please note that failure to submit this information will delay your admissions
process.
______ A minimum of three (3) letters of reference or support from non-family members if no longer on
probation and/or parole supervision (See Letter of Recommendation Form)
______ A personal interview after above items have been provided
______________________________________________ __________________
Student Signature Date
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Safety and Security Questionnaire
On your application for admission to the Great Falls College MSU, you answered in the affirmative to the
Safety and Security question: Have you ever been convicted of a felony (please include instances of
deferred sentencing)? In order for us to evaluate your application for admission further, please complete the
following questionnaire for each felony conviction. Please note that failure to submit detailed information
will delay your admission process.
1. Please list all Felony conviction(s) including court(s) in which conviction took place (state, city, county or
federal), date(s) of conviction(s), and sentence(s) imposed. Attach additional sheet if necessary.
Offense Court Date Sentence
a. ____________________________________________________________________________________
b. ____________________________________________________________________________________
c. ____________________________________________________________________________________
d. ____________________________________________________________________________________
e. ____________________________________________________________________________________
2. If any felony charges are still pending, please describe the situation and the anticipated completion
(adjudication) timeline:
3. Institution(s) where sentence(s) was served (prison, jail, pre-release, boot camp, etc) and length of time
served:
Correctional Institution Location Length of Incarceration
a. ____________________________________________________________________________________
b. ____________________________________________________________________________________
c. ____________________________________________________________________________________
d. ____________________________________________________________________________________
e. ____________________________________________________________________________________
4. Was violence involved in any of your crimes? Yes _____ No ______
If yes, please explain:
5. Circumstance(s) surrounding release from incarceration: (for example, for each conviction list whether
parole, probation, served time in full, etc):
a. ____________________________________________________________________________________
b. ____________________________________________________________________________________
c. ____________________________________________________________________________________
d. ____________________________________________________________________________________
e. ____________________________________________________________________________________
6. Nature of rehabilitation therapy (name, location) and amount completed (for example, Chemical
Dependency Treatment, MRT, Parenting, Anger Management, etc). Attach additional sheet if necessary.
Type of Treatment Location Length of Treatment
a. ____________________________________________________________________________________
b. ____________________________________________________________________________________
c. ____________________________________________________________________________________
d. ____________________________________________________________________________________
e. ____________________________________________________________________________________
f. ____________________________________________________________________________________
g. ____________________________________________________________________________________
h. ____________________________________________________________________________________
7. Are you currently involved in a support group(s)? Yes _____ No ______
If yes, type of group(s):
8. Are you currently involved in any treatment programs (mental health, chemical dependency, anger
management, etc.)? Yes _____ No ______
If yes, type of treatment:
9. If applicable, provide name, location and/or phone number of current rehabilitation (treatment) provider:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
Phone Number: ___________________________
Fax Number: _____________________________
10. Are you currently on: Probation: Yes ___ No ___ Parole: Yes ___ No ___
If no longer on probation or parole and sentence is expired, three letters of recommendation will be
required. Letter of recommendation documents can be submitted electronically (via the online application
process) or by printing and submitting the hard copy Letter of Recommendation form. Please contact
Admissions with any questions on documentation to be submitted.
If applicable, give name and contact information for parole/probation officer:
Name: __________________________________________________________________________
Phone Number (required): __________________________
Fax Number (required): __________________________
11. Attach record searches or sentencing information from the court(s) for each felony. If you do
not have your sentencing paperwork, you may also provide a full Montana criminal history that can be obtained
online at: http://www.doj.mt.gov/enforcement/criminaljustice/backgroundchecks.asp. If your conviction(s)
occurred outside the state of Montana or was a Federal conviction, you will need to contact each state, court or
Federal court to obtain the required information. Criminal histories downloaded from the Montana Department
of Corrections website will not fulfill this requirement.
PLEASE ALLOW 4-6 WEEKS FOR PROCESSING
RELEASE OF INFORMATION:
I hereby consent to the release of any and all information, by law enforcement officials, probation/parole
officers and others, relating to any arrests, convictions and probation/parole status for the violation(s) of any
state and federal laws. I give this consent to enable Great Falls College MSU to fully evaluate my
application for admission and acknowledge that the information provided will be so used.
Applicant’s Signature: __________________________________________________
Date of Authorization: __________________ Expiration Date: _______________
With my signature below, I certify that the information I have provided in this questionnaire is complete and
true. I understand that falsification or omission of information requested may result in denial of admission.
________________________________________ ________________________________________
Applicant’s Signature Print Name
_____________________________
Date
**If the Admissions Committee process is not completed, and you have not been admitted to Great Falls
College MSU within one year of application, all records regarding this matter will be destroyed.
Please return to: Great Falls College MSU
Office of Admissions ATTN: Brittany Budeski
2100 16
th
Avenue South
Great Falls, Montana 59405
(406) 771-4420 or (800) 446-2698
Please be advised that if you apply for admission to another Montana University System institution, a copy of this
form may be forwarded, upon administrative request, to the appropriate officials at that institution.
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Completed 18 November 2019

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