Have you ever been judged delinquent by a juvenile court or convicted of a misdemeanor or felony-level jurisdiction? Yes No
If so, please provide further details below, including the date, court and nature of the charge or conviction.
Please check all that apply: I am over the age of 25 I have not taken any college courses in the last 4 years
Dates of attendance:
Is this applicant eligible to return to your institution? Yes No
Has the applicant been subject to either disciplinary action or probation while attending your institution? Yes No
If yes, please explain:
Do you know of any other behavioral issues or concerns regarding this student’s attendance at your institution? Yes No
If yes, please explain:
Additional comments that may be helpful:
Student's Last Name - please print First Name, MI
SMU ID (optional)
Street Address/P.O. Box City, State, Zip
Phone Number S
tudent's Signature Date
Have you ever been subject to disciplinary action by any institution of higher education? Yes No
If yes, please provide further details below, including the nature of the disciplinary action and the name of the institution where the disciplinary action occurred.
If you have checked both boxes above, you do not need to complete the rest of this form.
“I have applied for admission to Saint Mary’s University of Minnesota for the academic term beginning ________________________, and I authorize
________________________________________ to release the following information. ___________
Name of College/University Student Initials
The student named above has applied for admission or readmission to Saint Mary’s University of Minnesota. This form must be on file before the
student will be considered for admission or readmission. Please complete the following questions:
Please return this form as soon as possible to:
Saint Mary’s University of Minnesota
Office of Admissions
700 Terrace Heights #2
Winona, MN 55987
800-635-5987, Ext. 1700
Saint Marys University of Minnesota
Dean of Students Form
After completing the top portion, submit this form to
your most recent
institution for final completion.
Signature of Dean Date
Printed Name Daytime Telephone Number
Name of Institution Institution Address
click to sign
click to edit