Ball State University School of Nursing
Entry Disclosure of Criminal Background
(Submitted during APPLICATION to the School of Nursing)
Please read and be honest when completing disclosure. Complete disclosure in ink.
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Name of Student (Print):__________________________________________________________
Maiden Name if Applicable (Print):___________________________________
Enter All Other Names Used (Print):__________________________________
BSUID Number: ________________________
Date of Birth: _________________________
6.
During the last 7 calendar years, except for minor violations of traffic laws resulting in fines,
(1) Have you ever been arrested or received a citation (e.g. drinking ticket,) for any misdemeanor charges?
_____ YES _____NO
(2) Have you ever been convicted of any misdemeanor charges? _____ YES _____NO
(3) Are there any current pending misdemeanor charges that have been filed against you? _____ YES _____NO
(4) Have you ever been arrested or received a citation for any felony charges? _____ YES _____NO
(5) Have you ever been convicted of any felony charges? _____ YES _____NO
(6) Are there any current pending felony charges that have been filed against you? _____ YES _____NO
(7) Have you entered into a prosecutorial diversion or deferment agreement regarding any offense, misdemeanor,
or felony? _____ YES _____NO
7. If you answered yes to any of the above questions, list all criminal arrests, citations and convictions you have received by
year, as well as any current pending criminal charges that have been filed against you. State requirements of probation,
deferral program or diversion program if applicable. List city & state of each criminal arrest, citation and convictions as well
as any pending criminal charges:
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8. If you answered “yes” to any questions above, when was the case dismissed? _____________________________
NOTE: You are required to submit official document from court stating “case dismissed” with date of dismissal.
All case closed documents must be turned in to CN 418.
**If you have previously turned in case closed documents and believe they are on file in CN 418, initial here: ___________
9. I understand that providing false information regarding my criminal history, failing to disclose requested information
regarding my criminal history, or not successfully passing any required criminal history check may result in a failure to be
approved for required placement assignments, and as such may result in my inability to progress through the BSU School of
Nursing programs, as such required placements are prerequisites to the completion of any School of Nursing degree. I
understand I must notify the Baccalaureate Program Coordinator, CN 418, of any pending/current charges.
Date: _______________ Signature: _________________________________________________