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					                     Kentucky State Police (KSP) Background Check
                           Department of Counseling and Student Affairs
                                         Western Kentucky University



    The College of Education and Behavioral Sciences has initiated a policy that includes a Kentucky State
Police Conviction Data background check as part of the application process for students enrolled in the
Counseling and Student Affairs programs. This background check is required for:

    *All students pursuing a master's degree in a counseling/student affairs program require a background
check. The background check is a critical part of the student's Application for Admission, Counseling and
Student Affairs Programs, (picture form). This application must be completed and approved by the counseling
faculty BEFORE a student is permitted to enroll in Practicum.

   * A students in a Rank I or Certification Only program or any student not pursuing a master's degree MUST
complete the background check prior to participation in Practicum or Internship.

   NOTE: Practicum is a RESTRICTED CLASS and requires a course pass. Contact the Department of
Counseling and Student Affairs at 270-745-4953 in order to secure a course pass. Students whose records are
complete will be allowed to register for the practicum.

     Completing this background check is an important and necessary part of the program. Students should
initiate this check early in their matriculation so it will be in their file when needed. The Request of KSP
Conviction Data form is contained in the Application for admission and is available by mail from the
Department of Counseling and Student Affairs, Gary Ransdell Hall 2011, 270-745-4953, and will also be
available online from the department.

    Students are to complete the form and forward it to the Kentucky State Police. Include a $20.00 check or
money order made payable to the Kentucky State Treasurer. Requests should be accompanied by two, self –
addressed stamped envelopes – one bearing the name and address of the requesting agency (Department of
Counseling Programs – Records, Gary Ransdell Hall 2011, Western Kentucky University, 1906 College Heights
Blvd. #51031, Bowling Green, KY 42101) and the other bearing the name and address of the student.

    See the form below for detailed instructions.
                          REQUEST FOR CONVICTION RECORDS/ MINORS
Pursuant to KRS 17.160, request is made for any record of conviction found in the files of the Kentucky centralized
criminal history record information system regarding the person identified herein. This information shall be released to:

Western Kentucky University – Counseling & Student Affairs, 1906 College Heights Blvd. GRH 2011
Bowling Green, KY 42101-1031

Organization Name and Address

ACKNOWLEDGMENT BY APPLICANT

I have applied for employment or a volunteer position with the above named organization involving supervisory or
disciplinary power over a minor. I am requesting that the Kentucky State Police provide the employer with any record of
conviction found in the files of the Kentucky centralized criminal history record information system. I know that I have the
right to inspect my criminal history record and to request correction of any inaccurate information. If I do not exercise that
right, I agree to hold harmless the Kentucky State police and any Kentucky State Police employee(s) from any claim for
damages arising from the dissemination of inaccurate information.

APPLICANT INFORMATION (PLEASE PRINT)

NAME: ________________________________________________________________________________________
      Last                    First                 Middle                       Maiden

ADDRESS: _____________________________________________________________________________________
         Street                                      City                State       Zip

SEX_____ RACE _______ DATE OF BIRTH ___________________ SOC SEC NO _________________________

__________________________________________                     _____________________________________________
Signature                      Date                            Witness                            Date

INSTRUCTIONS:

Requesting agencies should ensure that all application information is completed.

Requesting agencies should forward a check or money order made payable to the Kentucky State Treasurer in the amount
of $20.00 for each submitted form. Requests should be accompanied by two, self –addressed stamped envelopes – one
bearing the name and address of the requesting agency and the other bearing the name and address of the applicant.

The Kentucky State Police will charge a $25.00 fee on each returned check.

RETURN THIS FORM TO:                         Kentucky State Police
                                             Criminal Identifications and Records Branch
                                             Criminal Records Dissemination Section
                                             1266 Louisville Road
                                             Frankfort, KY 40601

                                             Visit us online @ http:\\kentuckystatepolice.org

Revised 10/08

				
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posted:9/21/2012
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