Disciplinary Records Request

Background Information

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Today's Date(Required):

This field is required.

Your Information

Please provide all of this information; if you do not know/recall your Student ID number, you may leave that field blank. Your current phone, address, and email are important in case we need to contact you.

Your Full Name Used at Mercy

Your Mercy ID Number

Your Date of Birth (MM-DD-YYYY)

Current Phone number

Current Email address

Additional Information

When did you attend Mercy? (Please provide the first and last terms you attended)(Required) This field is required.

Please list the name, email, and organization of each of the parties to which we should send this report. Example: Mercy Maverick, mmaverick@mercy.edu, Mercy University.(Required) This field is required.

If you have a specific candidate or applicant number that we need to reference on our report, please enter it below. This field is required.

Other comments or specific requests? This field is required.

Your consent is required, by the Family Education Rights and Privacy Act of 1974, as amended (“FERPA”), for Mercy University to release any personally identifiable information from your education records not defined as “Public Information” under the University's FERPA policy. Enter your full name below to confirm your permission for Mercy University to release your disciplinary records information to the above noted entities.(Required) This field is required.

Supporting Documentation

Upload any documents/forms from the organizations to which you want us to send a report. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Background Information

Your Information

Additional Information

Supporting Documentation

Submission