Conduct Clearance Form

Basic Personal Information

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Your full name:

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(First Name, Last Name)

Your phone number:

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Cell phone preferred

Your email address:

Email address must be of a valid format.

Date of incident(Required):

This field is required.

Your Personal Information (All Fields Required)

Please provide the following information in the fields below.

Name (First Name Last Name)

Gender

Select Role

UMD UID Number (if known)

DOB (YYYY-MM-DD)

Cell Phone number

Email address

Permanent Address

Personal Statement and Required Questions

Incident(s) Description In the space below write a detailed, factual description of the incident which resulted in disciplinary action. You may include the circumstances which led up to the occurrence of each incident as well as the outcome. This allows you to explain in your own words what happened regarding the situation. Additionally, please include what the specific sanctions/outcomes that were associated with your case and information regarding your sanction completion status. Note: If you disclosed multiple incidents, please address each individually in your statement.(Required) This field is required.

Personal Statement In the space provided please write a personal statement reflecting upon what you have learned from this situation. How did the incident impact you, your family, and the surrounding community? How will you avoid situations such as these in the future (be specific)?(Required) This field is required.

Other Information to Consider In this statement, you may consider addressing what you have been doing since the incident occurred to demonstrate learning and growth. This includes whether you are involved in extracurricular activities or community service, whether you are/were employed and for how long, whether you are/were enrolled in another institution and what are your academic plans, and any other information you feel would be helpful in the evaluation your application.(Required) This field is required.

Past Behavioral/Disciplinary Conduct You must provide the following documentation in the section below titled Supporting Documentation:1. Copies of all letters regarding the incident and proof that sanctions have been completed; or 2. A letter of standing from the school or college you were attending at the time the incident occurred, indicating whether or not you completed sanctions and are eligible to re-enroll. The letter from the school or college must be on the institution’s letterhead and be signed by the administrator.(Required)

I understand that I must provide the aforementioned supporting documentation for past behavioral/disciplinary misconduct reported.

You must make at least one selection.

Please indicate if you are an undergraduate, graduate, non-degree seeking applicant.(Required)

Undergraduate Graduate Non-degree seeking

This field is required.

Please indicate what semester you are applying for (example: Fall 2023).(Required) This field is required.

Are you seeking re-enrollment to the University of Maryland?(Required)

Yes No

This field is required.

Supporting Documentation

Attach the required documents as outlined above. Please attach items as individual documents and title them accordingly (example: Outcome Letter, Sanction Notice, Incident Report, Letter of Good Standing, etc...). 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Basic Personal Information

Your Personal Information (All Fields Required)

Personal Statement and Required Questions

Supporting Documentation

Submission