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SQ 4 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. It has come to the attention of the Admissions Office that you
have marked or will have to mark affirmative to one 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 that is with this letter
SIGN and DATE the Consent to Release Information which is located in 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:
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 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@gfcmsu.edu. Please keep this letter for your records.
Sincerely,
Brittany Budeski
Director of Admissions and New Student Services
Enc: SQ4
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 required to register as a sexual or violent offender?
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 each
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 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 required to register as a sexual or violent offender? 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. Which type of offender registration were you required to complete?
Violent: Yes ___ No ___ Sexual: Yes ___ No ___
2. Please list all conviction(s) requiring registration, 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. ____________________________________________________________________________________
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. Please explain the circumstances that resulted in you no longer having to register as a violent or sexual
offender:
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, Sex Offender, 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 rehabilitation (treatment) provider:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
Phone Number: ___________________________
Fax Number: _____________________________
10. Are you currently on: Probation: Yes ___ No ___ Parole: Yes ___ No ___
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 conviction. 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. Paperwork
related to your offense may be obtained from the court in which your conviction occurred. Criminal histories
downloaded from the Montana Department of Corrections website will not fulfill this requirement.
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.
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
Admissions Office 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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