190 West Campus Drive
New Hall West, Suite 141
Blacksburg, Virginia 24061
P: (540) 231-3790 F: (540)
231-3437
studentconduct@vt.edu
Self-Disclosure of Arrest(s)/Conviction(s) Form
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Last Name
First Name
Student ID#
Birthdate
Address
MI
Cell/Local Phone #
City
VT Email Address
State
Zip Code
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Charge(s)RULVVXDQFHRIDSURWHFWLYHRUGHU:
Incident Location
City
County
Court/Jurisdiction
Date of Next/Last Hearing
Yes Ƒ
Have you pled or been found guilty?
If guilty, what charges were you convicted of?
State
No Ƒ
Date
Yes Ƒ
Were charges dropped?
No Ƒ
Describe sentence or action imposed by the court (eg: period of actual or suspended incarceration,
educational program, fine, etc.)
Yes Ƒ
No Ƒ
Are you currently on Probation or Parole?
Has the University Conduct System taken action on this incident(s)?
If yes, provide any information you have on your student conduct record:
Yes Ƒ
Signature
No Ƒ
Date
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Reviewed by:
Student Conduct Action?
Checked Admissions?
Notes:
Date
Yes Ƒ
Yes Ƒ
NoƑ
NoƑ
Entered into Database
Case #:
Yes Ƒ
NoƑ