After downloading and completing the applicant questions below, share this form with a college ofcial at the school
from which you are transferring who has access to your student disciplinary and academic record. If you are unsure of
whom to contact at your current institution, we recommend contacting the dean of students, Ofce of the Registrar, or
your faculty/staff advisor to ask about the appropriate contact.
APPLICANT
Student Name _____________________________________________________________________________________________
Last First Middle Initial Jr., etc.
Date of Birth _____________________________ Notre Dame Applicant ID Number _______________________________
mm/dd/yyyy
I authorize all colleges and universities I’ve attended to release all requested records and authorize review of my
application for the admission process indicated on this form.
Under the 1974 Family Educational Rights and Privacy Act, if you enroll at the University of Notre Dame,
you will have access to this form and all other recommendations and supporting documents submitted
by you and on your behalf after matriculating, unless you waive your right to access. Please select one of
the following statements:
I waive my right to access all recommendations and supporting documents submitted by me or
on my behalf.
I DO NOT waive my right to access all recommendations and supporting documents submitted
by me or on my behalf.
• I understand that my decision may lead my counselors or teachers to decline to write
recommendations on my behalf. I also understand that my decision may lead the
University of Notre Dame to disregard any recommendation submitted on my behalf.
Applicant Signature ______________________________________ Date _____________________________
COLLEGE STUDENT RECORD FORM
COLLEGE OFFICIAL
COLLEGE OFFICIAL
Institution Name ___________________________________________________________ CEEB _________________________
Address ___________________________________________________________________________________________________
___________________________________________________________________________________________________
Phone _____________________________________ Email Address ________________________________________________
Name of College Ofcial ________________________________________ Title _____________________________________
Student Name _____________________________________________________________________________________________
Has the applicant ever been found responsible for a disciplinary violation at your school, whether related to academic
misconduct or behavioral misconduct, that resulted in the applicant’s probation, suspension, removal, dismissal , or
expulsion from your institution? Yes No
To your knowledge, has the applicant ever been convicted of a misdemeanor, felony or other crime? Yes No
If you answered “yes” to either or both questions, please provide details or use your letter of recommendation to give
the approximate date of each incident and explain the circumstances.
Is this applicant eligible to return to your institution? Yes No
Is this student in good academic standing? Yes No
If you answered “no” to either or both questions, please provide details.
I recommend this student:
No Basis With reservation Fairly Strongly Strongly Enthusiastically
College Official Signature ______________________________________________ Date _____________________________
Please save and submit this completed form to the
Ofce of Undergraduate Admissions at the University of Notre Dame
at [email protected] with the subject line “College Student Record Form - [Student’s Last Name]”
