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Liaison

Other Information

Military Status

If you have US military experience, select your anticipated status at the time of enrollment from the drop-down. Select Not a member of the military if this does not apply.

License Infraction

Indicate whether you have ever had any certification, registration, license, or clinical privileges revoked, suspended, or in any way restricted by an institution, state, or locality. If yes, enter an explanation in the spaces provided.

Academic Infraction

Indicate whether you have ever been disciplined or placed on academic probation while attending an academic institution. If you select Yes, enter a brief explanation in the field provided. Include 1) a brief description of the incident, 2) specific charge made, 3) related dates, 4) consequence, and 5) a reflection on the incident and how the incident has impacted your life.

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