Dean's Reference Form

Dean’s Reference Form - Part 1

This form is to be completed and submitted by transfer applicant. Please complete this section with your information and list the contact information for dean of students or registrar of the college you are now attending, or the last college you attended. Upon submission, the college official will receive an email with a link to another form they will need to complete and submit on your behalf.

* required field

Student Information

First Name*

Middle Name

Last Name*

Birthdate* (for identification purposes only)

Email Address*

Address*

Country

Street

City

Region

Postal Code

Disciplinary Information

Have you ever been found responsible for a disciplinary violation at any educational institution you have attended or military service, that resulted in a disciplinary action? These actions could include, but are not limited to: probation, suspension, removal, dismissal/discharge, or expulsion from the institution/service*

Yes

No

Please explain the circumstances of each incident and reflect on what you learned from the experience.*

Have you ever been adjudicated guilty or convicted of a misdemeanor or felony? Note that you are not required to answer "yes" to this question, or provide an explanation, if the criminal adjudication or conviction has been expunged, sealed, annulled, pardoned, destroyed, erased, impounded, or otherwise required by law or ordered by a court to be kept confidential.*

Yes

No

Please provide the details of your criminal conviction or adjudication and reflect on what you learned from the experience.*

College Information

Please enter the college you are now attending, or your most recently attended college, as well as the contact information for dean of students or registrar from this college.

College Name*

College City*

College State*

Contact information of college official

College Official First Name*

College Official Last Name*

College Official Title*

College Official Email*

College Official Phone*

Signature & Submit

I acknowledge that every school that I have attended may release all requested records, recommendations and supporting documents to other schools to which I am applying for admission. I also understand that employees at each school to which I am applying for admission may contact my current and former schools should they have questions about the information submitted on my behalf.*

I waive my right to review the records, recommendations and supporting documents submitted on my behalf for admission.

I DO NOT waive my right to review the records, recommendations and supporting documents submitted on my behalf for admission.

I understand that the above election to waive/not to waive may not be changed after any recommendation or application submission.*

Do you give RWU permission to contact the college official listed on your behalf?*

Yes, I give RWU permission to contact the college official listed

No, I do not give RWU permission to contact the college official I listed. Please contact me with next steps.

Student Signature* (please type your name in for your signature)