Move the Box - Form A

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Move the Box - Form A

Failure on a student's part to submit this form will result in denial of admission to the internship experience, course, or program of interest.

Make sure to select submit after you complete the form!
Student Name Student Name * First Last
Banner # (Student ID) *
SSN (Last 4 Digits) *
Maximum of 4 digits allowed. Currently Entered: 0 digits.
Application / Registration for: *

Application / Registration for: Academic Major Clinical Internship Field Experience Course BCEC Study Abroad
Course # *
Sponsoring Department *

This is the department that is sponsoring the program / experience.
Have you ever been convicted of a felony or do you have a pending felony charge? *

Have you ever been convicted of a felony or do you have a pending felony charge? Yes No
If yes, briefly describe your situation below. (Additional questions and forms will be e-mailed to the e-mail address you gave.)*
Student Email Address *

This is the e-mail address we will use if additional information needs to be sent to you based on your answers. Make sure to enter an e-mail address you check.
*State University of New York (SUNY) Policy prohibits admission applications from inquiring into an applicant's prior criminal history. After acceptance, the College shall inquire if the student previously has been convicted of a felony if such an individual seeks campus housing or participation in clinical or field experience, internships or study abroad programs. The information required to be disclosed under SUNY policy regarding such felony convictions shall be reviewed by a standing campus committee consistent with the legal standards articulated in New York State Corrections Law.
*Students who have previously been convicted of a felony are advised that their prior criminal history may impede their ability to complete the requirements of certain academic programs or meet licensing requirements for and be eligible for employment in certain professions. Students who have concerns about their status are advised to contact the department chair of their intended academic program.
NOTE: By submitting this form, you are confirming that all information is complete and accurate.

Should your status change prior to the semester of the program / experience you are applying for, it is your responsibility to notify the chair of the sponsoring department.

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Main Page Content

Move the Box - Form A

Failure on a student's part to submit this form will result in denial of admission to the internship experience, course, or program of interest. Make sure to select submit after you complete the form!

NOTE: By submitting this form, you are confirming that all information is complete and accurate. Should your status change prior to the semester of the program / experience you are applying for, it is your responsibility to notify the chair of the sponsoring department.

Failure on a student's part to submit this form will result in denial of admission to the internship experience, course, or program of interest.

Make sure to select submit after you complete the form!

NOTE: By submitting this form, you are confirming that all information is complete and accurate.

Should your status change prior to the semester of the program / experience you are applying for, it is your responsibility to notify the chair of the sponsoring department.