VIRGINIA STATE UNIVERSITY
Office of Undergraduate Admissions
P.O. Box 9018, Virginia State University, VA 23806
PHONE: (804) 524-5902
FAX: (804) 524-5055
E-MAIL: admissions@vsu.edu
CONFIDENTIAL REPORT
STUDENT’S NAME:
LAST FIRST M.I.
SOCIAL SECURITY NUMBER: - - DATE OF BIRTH: - -
MM DD YYYY
This form must be completed by the Dean of Students, Registrar or designated official of the last college attended and forwarded to the
Virginia State University Office of Admissions at admissions@vsu.edu
, faxed to (804) 524-5055 or sent to the mailing address above.
NAME OF COLLEGE/UNIVERSITY:
DATES OF ATTENDANCE: FROM TO
MONTH/YE AR
YES NO
1. Is this student on academic or social probation?
2. Has this student:
a) been disciplined for any infractions of rules?
b) been suspended at any time?
If yes, please list infraction(s)/suspension(s) and stipulations/outcomes below.
3. Could this student return to your school at the next regular enrollment?
If no, please explain reason(s) and stipulation(s) in the space provided below.
In the space below, please provide additional information to assess this student’s eligibility for admission to Virginia State University.
NAME: TITLE:
SIGNATURE: DATE:
rev.6.2020
“VSU: Education, Research and Community Service in Central and Southside Virginia…”
An Equal Opportunity Employer/Equal Access Institution
MONTH/YE AR
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signature
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