IEC Non-Credit Program Registration 23-24

All applicants who answer 'yes' to the criminal history question will go through an additional review once it is determined that the application is academically eligible for admission. This review process may include a background check and some applicants may be asked to provide agency of records which include arrest reports and related court documents. If desired, you may upload these documents below to expedite the review process. More information about the admission procedures for applicants with criminal history can be found on our website.

Arrest reports and court records upload

Social Security Number (required if US citizen or permanent resident)

Aliases. Include all previous names, dates the names were used, reasons (i.e. prior marriage, maiden name, etc.)

Marital status

Date of marriage

Date of divorce

Driver's license number

State in which driver's license was issued

Expiration date

Driver's license suspensions

List all states in which you have lived. If you are not yet in the US, please enter "NA."

Are you currently on parole or probation?

Please provide the name, address, email address, and phone number of your parole or probation officer.

Name

Agency

Agency Address

Country

Street

City

Region

Postal Code

Agency Email Address

Agency Phone Number

Please enter the length of your parole or probation.

Please enter the terms of your parole or probation.

Are you currently in a community corrections program or a resident of a halfway house?

Provide the name, address, and phone number of the facility and your supervisor's name and email address.

Facility name

Facility phone number

Facility address

Country

Street

City

Region

Postal Code

Supervisor name

Supervisor email address

Are you currently required to register as a sex offender?

Yes

List all law enforcement infractions. Detail any additional infractions in the text box provided below.

Incident 1 (All fields required for Incident 1)

Date of incident

Arresting law enforcement agency (i.e. name of police department or other arresting agency)

Case Number

Offense Charged

Court disposition and sentence (i.e. plea agreement, time in custody, probation terms, etc.)

Incident 2

Date of incident

Arresting law enforcement agency (i.e. name of police department or other arresting agency)

Case number

Offense Charged

Court disposition and sentence (i.e. plea agreement, time in custody, probation terms, etc.)

Incident 3

Date of incident

Arresting law enforcement agency (i.e. name of police department or other arresting agency)

Case number

Offense Charged

Court disposition and sentence (i.e. plea agreement, time in custody, probation terms, etc.)

Incident 4

Date of incident

Arresting law enforcement agency (i.e. name of police department or other arresting agency)

Case number

Offense Charged

Court disposition and sentence (i.e. plea agreement, time in custody, probation terms, etc.)

Additional incidents if applicable. Be sure to include dates, arresting law enforcement agencies, case numbers, offenses charged, and court dispositions and sentences for each additional incident.

Provide a detailed explanation of the incident(s) and outcome. Include information about what you have done since the incident, treatment you have undergone, lessons learned, etc.

(Required)

Sign the statement and Authorization for Release of Information below:

By typing my name below, I hereby certify that to the best of my knowledge, the information furnished above is accurate, true and complete. I understand that if it found to be otherwise, it is sufficient cause for refusal, dismissal, or discipline. I authorize representatives of the University of Colorado Boulder to make any and all appropriate inquiries regarding the information listed in this supplement, including conducting a criminal history background check through a third party provider.

I hereby release the university, its officers, employees, and representatives from any liability or damage that may result from furnishing the information requested or conducting the background check.

Applicant signature

Date

By submitting your registration form, you certify that to the best of your knowledge, the information submitted in this form is true and complete. You understand that if found to be otherwise, it is sufficient cause for refusal or dismissal. You also agree to all terms and conditions as discussed in this form.

In place of your signature, please type your full legal name and then hit enter:*