Office of Admission Instructions to student: Please complete Section A and forward to the Dean of Students at the last college you attended or are currently attending. This form must be on file in the Bethel University Office of Admission before you will be allowed to enroll. Section A I hereby authorize the Dean of Students to complete Section B and submit this form to the Office of Admission at Bethel University. Student Name:_______________________________________________ (Print) _______________________________________________ (Sign)

Date:___________________ ________________________ (Social Security Number)

Section B Instruction to Dean of Students: Please complete Section B as accurately as possible. 1. Is this student currently enrolled at your institution?

Y

N

2. Has the student received official disciplinary action?

Y

N

3. Has the student been arrested, charged, or convicted of a criminal offense or been involved in the use, purchase, or distribution of alcoholic beverages or drugs?

Y

N

4. Has the student been found with the possession of firearms?

Y

N

5. Has the student exhibited behavior which would hinder typical social interaction?

Y

N

6. Has the student exhibited emotional disorders or been under psychiatric care?

Y

N

7. If not stated above, is there any reason why the student should not be admitted?

Y

N

*If yes on question 2 through 7 please explain on a separate sheet. Dean of Students:______________________________________________

Date:___________________

Institution:___________________________________________________

Telephone:_______________

*Please mail or fax to:

Bethel University Enrollment Services PO Box 130 McKenzie, TN 38201 731-352-4241 (Fax)