CAMPUS SAFETY QUESTIONS – OMS - Meharry Medical College

Your “yes” answer to one or more of the following questions will not necessarily preclude your being admitted. However, your failure to provide complete, accurate, and truthful information will be grounds to deny or withdraw your admission, or to dismiss you after enrollment.

For the purpose of the following six questions, “crime “or “criminal charge “refers to any crime other than a traffic-related misdemeanor or an infraction. You must, however, include alcohol or drug offenses whether or not they are traffic related.

1. Have you ever been convicted of a crime?*

Yes
No

2. Have you ever entered a plea of guilty, a plea of no contest (nolo contendere) or an Alford plea, or have you received a deferred prosecution or Prayer for Judgment Continued, to a criminal charge?*

Yes
No

3. Have you otherwise accepted responsibility for the commission of a crime?*

Yes
No

4. Do you have any criminal charges pending against you?*

Yes
No

5. Have you ever been expelled, dismissed, suspended, placed on probation, or otherwise subject to any disciplinary sanction by any school, college or university?*

Yes
No

6. If you have ever served in the military, did you receive any type of discharge other than an honorable discharge?*

Yes
No
Currently Serving
Never Served

If you answered “yes “to any of the six questions above, please explain the circumstances below.

You must promptly notify the admissions office in writing of any criminal charge, any disposition of a criminal charge, or any school, college, or university disciplinary action against you, or any type of military discharge other than an honorable discharge that occurs at any time after you submit this application. Your failure to do so will be grounds to deny or withdraw your admission or to dismiss you after enrollment.*

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The Oral and Maxillofacial Surgery Residency program is a four-year commitment. Early withdrawal from the program for any reason, prior to the end of the terms of the commitment, is a breach of contract, and you will be held financially liable.*

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Name*

First Last

Signature*

The electronic signature denotes that the information you provide is truthful and complete.

Date*